1457582066 NPI number — MEGAN NICHOL HEIDKAMP FAVREAU OT

Table of content: MEGAN NICHOL HEIDKAMP FAVREAU OT (NPI 1457582066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457582066 NPI number — MEGAN NICHOL HEIDKAMP FAVREAU OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAVREAU
Provider First Name:
MEGAN
Provider Middle Name:
NICHOL HEIDKAMP
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEIDKAMP-YOUNG
Provider Other First Name:
MEGAN
Provider Other Middle Name:
NICHOL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457582066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
133 FAIRFIELD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT ALBANS
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05478-1726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-524-1064
Provider Business Mailing Address Fax Number:
802-524-1025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133 FAIRFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT ALBANS
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05478-1726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-524-1064
Provider Business Practice Location Address Fax Number:
802-524-1025
Provider Enumeration Date:
07/30/2009

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: 225X00000X , with the licence number:  072.0053032 , 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)