1679728356 NPI number — ERIN KATHLEEN IMMKEN LPC, LCPC

Table of content: ERIN KATHLEEN IMMKEN LPC, LCPC (NPI 1679728356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679728356 NPI number — ERIN KATHLEEN IMMKEN LPC, LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IMMKEN
Provider First Name:
ERIN
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOSTICK
Provider Other First Name:
ERIN
Provider Other Middle Name:
KATHLEEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC, LCPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679728356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 98
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDWARDSVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62025-0098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-710-4123
Provider Business Mailing Address Fax Number:
618-731-4082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 JUNCTION DRIVE WEST
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
GLEN CARBON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-710-4123
Provider Business Practice Location Address Fax Number:
618-731-4082
Provider Enumeration Date:
11/24/2008

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:  2008034953 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: 180.006806 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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