1215119201 NPI number — THEODORE COOPER SUTTON FSWC I/COUNSELOR

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215119201 NPI number — THEODORE COOPER SUTTON FSWC I/COUNSELOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUTTON
Provider First Name:
THEODORE
Provider Middle Name:
COOPER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FSWC I/COUNSELOR
Provider Gender Code:
M

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:
1215119201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BRISTOL BAY AREA HEALTH CORPORATION
Provider Second Line Business Mailing Address:
TOGIAK BEHAVIORAL HEALTH PROGRAM, P.O. BOX 409
Provider Business Mailing Address City Name:
TOGIAK
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99678-0409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-493-5637
Provider Business Mailing Address Fax Number:
907-493-5184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MAIN STREET BRISTOL BAY AREA HEALTH CORPORATION
Provider Second Line Business Practice Location Address:
TOGIAK BEHAVIORAL HEALTH PROGRAM, FAMILY RESOURCE BLD.
Provider Business Practice Location Address City Name:
TOGIAK
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99678-0409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-493-5637
Provider Business Practice Location Address Fax Number:
907-493-5184
Provider Enumeration Date:
11/30/2007

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: 101YA0400X , with the licence number:  RHS CERTIFICATION , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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