1538377932 NPI number — MYSTI RACHELLE RAINWATER LPC

Table of content: MYSTI RACHELLE RAINWATER LPC (NPI 1538377932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538377932 NPI number — MYSTI RACHELLE RAINWATER LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAINWATER
Provider First Name:
MYSTI
Provider Middle Name:
RACHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANAKEN
Provider Other First Name:
MYSTI
Provider Other Middle Name:
RACHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538377932
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11011 S 48TH ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85044-1779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-223-8263
Provider Business Mailing Address Fax Number:
480-632-9639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11011 S 48TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85044-1779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-223-8263
Provider Business Practice Location Address Fax Number:
480-632-9639
Provider Enumeration Date:
05/18/2007

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: 101YP2500X , with the licence number:  LPC-12651 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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