1871930123 NPI number — RENA L BRADYMIRE LPC

Table of content: RENA L BRADYMIRE LPC (NPI 1871930123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871930123 NPI number — RENA L BRADYMIRE LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADYMIRE
Provider First Name:
RENA
Provider Middle Name:
L
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:
MINTER
Provider Other First Name:
RENA
Provider Other Middle Name:
LORINNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1871930123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2201 N GOVERNMENT WAY STE K
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814-3658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-664-0552
Provider Business Mailing Address Fax Number:
209-262-9698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2201 N GOVERNMENT WAY STE K
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814-3658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-664-0552
Provider Business Practice Location Address Fax Number:
209-262-9698
Provider Enumeration Date:
05/28/2013

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: 101YM0800X , with the licence number:  LH60074397 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LPC-3454 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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