1407932296 NPI number — MR. JONATHAN MICHAEL LEAGUE LPCC, LCDC

Table of content: MR. JONATHAN MICHAEL LEAGUE LPCC, LCDC (NPI 1407932296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407932296 NPI number — MR. JONATHAN MICHAEL LEAGUE LPCC, LCDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAGUE
Provider First Name:
JONATHAN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPCC, LCDC
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:
1407932296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6400 THORNBERRY COURT
Provider Second Line Business Mailing Address:
UNITE 620
Provider Business Mailing Address City Name:
MASON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-229-8386
Provider Business Mailing Address Fax Number:
513-229-8385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6400 THORNBERRY COURT
Provider Second Line Business Practice Location Address:
UNITE 620
Provider Business Practice Location Address City Name:
MASON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-229-8386
Provider Business Practice Location Address Fax Number:
513-229-8385
Provider Enumeration Date:
10/27/2006

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: 101YA0400X , with the licence number:  021055 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: E 4364 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: E 4364 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000000477472 . This is a "BCBS/ANTHEM ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".