1104142447 NPI number — CARA GLEASON KREBS L.I.C.S.W.

Table of content: CARA GLEASON KREBS L.I.C.S.W. (NPI 1104142447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104142447 NPI number — CARA GLEASON KREBS L.I.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KREBS
Provider First Name:
CARA
Provider Middle Name:
GLEASON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.I.C.S.W.
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:
1104142447
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 FLYNN AVE
Provider Second Line Business Mailing Address:
SUITE 3J
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401-5429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-488-6300
Provider Business Mailing Address Fax Number:
802-488-6919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1138 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401-5353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-488-6600
Provider Business Practice Location Address Fax Number:
802-488-6919
Provider Enumeration Date:
04/12/2010

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: 1041C0700X , with the licence number:  089.0063049 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1017781 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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