1225087455 NPI number — ROBERT J FORTGANG MA, LCMHC

Table of content: ROBERT J FORTGANG MA, LCMHC (NPI 1225087455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225087455 NPI number — ROBERT J FORTGANG MA, LCMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTGANG
Provider First Name:
ROBERT
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LCMHC
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:
1225087455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAMPTON
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03256-0266
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:
118 PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05156-3030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-387-4927
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2006

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: 101YM0800X , with the licence number:  068-0000243 , 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: 1010554 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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