1093816043 NPI number — MRS. CYNTHIA MARIE ELIZONDO LPC

Table of content: MRS. CYNTHIA MARIE ELIZONDO LPC (NPI 1093816043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093816043 NPI number — MRS. CYNTHIA MARIE ELIZONDO LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELIZONDO
Provider First Name:
CYNTHIA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093816043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1307 GOODRICH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55105-2708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-695-1022
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 UNIVERSITY AVE W
Provider Second Line Business Practice Location Address:
SUITE 229N
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-645-3115
Provider Business Practice Location Address Fax Number:
651-645-2752
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  00299 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41-1576550 . This is a "PRACTICE FED TAX ID#" identifier . This identifiers is of the category "OTHER".




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