1982760625 NPI number — MS. SHAUN L PHOENIX LCPC

Table of content: MS. SHAUN L PHOENIX LCPC (NPI 1982760625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982760625 NPI number — MS. SHAUN L PHOENIX LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHOENIX
Provider First Name:
SHAUN
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

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:
1982760625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 LITTLE BROOK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELGRADE
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59714-9533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-580-0562
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 S 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59715-4443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-580-0562
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2006

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: 101YM0800X , with the licence number:  914 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000252518 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1982760625 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".