1891839452 NPI number — DR. KERRY LEE GARRETSON PH.D.

Table of content: DR. KERRY LEE GARRETSON PH.D. (NPI 1891839452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891839452 NPI number — DR. KERRY LEE GARRETSON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARRETSON
Provider First Name:
KERRY
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891839452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4986 COUNTY ROAD 6 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELTA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43515-9241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6912 SPRING VALLEY DR
Provider Second Line Business Practice Location Address:
SUITE 202C
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43528-9676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-866-4644
Provider Business Practice Location Address Fax Number:
419-861-5040
Provider Enumeration Date:
02/16/2007

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: 103T00000X , with the licence number:  2500 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TB0200X , with the licence number: 2500 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0528003 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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