1720185408 NPI number — MARILYN ELLLEN KOVTUNOVICH LCSW

Table of content: MARILYN ELLLEN KOVTUNOVICH LCSW (NPI 1720185408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720185408 NPI number — MARILYN ELLLEN KOVTUNOVICH LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOVTUNOVICH
Provider First Name:
MARILYN
Provider Middle Name:
ELLLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VICCARO
Provider Other First Name:
MARILYN
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1720185408
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97520-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-482-1278
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97520-6800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-482-1278
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2006

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: 1041C0700X , with the licence number:  490 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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