1285767913 NPI number — MRS. HEATHER SUE TUSTISON LCPC

Table of content: MRS. HEATHER SUE TUSTISON LCPC (NPI 1285767913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285767913 NPI number — MRS. HEATHER SUE TUSTISON LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUSTISON
Provider First Name:
HEATHER
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMPSON
Provider Other First Name:
HEATHER
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285767913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2176 E FRANKLIN RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-8009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-869-0199
Provider Business Mailing Address Fax Number:
208-908-6164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2176 E FRANKLIN RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-869-0199
Provider Business Practice Location Address Fax Number:
208-908-6164
Provider Enumeration Date:
03/13/2007

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: 101Y00000X , with the licence number:  LCPC-4258 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LCPC-4258 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP1600X , with the licence number: LCPC-4258 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LCPC-4258 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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