1366598542 NPI number — MS. MARY JANE NIELSEN MSSA, LISW

Table of content: MS. MARY JANE NIELSEN MSSA, LISW (NPI 1366598542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366598542 NPI number — MS. MARY JANE NIELSEN MSSA, LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIELSEN
Provider First Name:
MARY
Provider Middle Name:
JANE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSSA, LISW
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:
1366598542
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:
9138 PAYNE FARM LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45458-9388
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-885-3782
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3095 KETTERING BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45439-1921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-293-8300
Provider Business Practice Location Address Fax Number:
937-534-1347
Provider Enumeration Date:
01/28/2007

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: 104100000X , with the licence number:  I4458 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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