1487664553 NPI number — MRS. JUDITH ANNE HART LCDP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487664553 NPI number — MRS. JUDITH ANNE HART LCDP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HART
Provider First Name:
JUDITH
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCDP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEGNER
Provider Other First Name:
JUDITH
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCDP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487664553
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
163 SLATER PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWTUCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02861-3213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-440-0472
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 WAMPANOAG TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-431-9870
Provider Business Practice Location Address Fax Number:
401-435-7486
Provider Enumeration Date:
08/09/2006

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:  LCDP00173 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: MHC00362 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: JL58361 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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