1114272929 NPI number — MELANIE GARDNER LPC, ATR-BC, CTS

Table of content: MELANIE GARDNER LPC, ATR-BC, CTS (NPI 1114272929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114272929 NPI number — MELANIE GARDNER LPC, ATR-BC, CTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
MELANIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, ATR-BC, CTS
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:
1114272929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3144
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PETERSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23805-3144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 217
Provider Business Practice Location Address City Name:
HOPEWELL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23860-2720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-892-9262
Provider Business Practice Location Address Fax Number:
804-732-8233
Provider Enumeration Date:
07/17/2012

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:  0701005249 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 221700000X , with the licence number: 08-136 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 221700000X , with the licence number: 08-136 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1114272929 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".