1003122987 NPI number — MRS. BRENDA JO ERIE LICSW

Table of content: MRS. BRENDA JO ERIE LICSW (NPI 1003122987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003122987 NPI number — MRS. BRENDA JO ERIE LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERIE
Provider First Name:
BRENDA
Provider Middle Name:
JO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
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:
1003122987
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
448 21ST ST W STE D-1
Provider Second Line Business Mailing Address:
THERAPY SOLUTIONS
Provider Business Mailing Address City Name:
DICKINSON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58601-3462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-483-1000
Provider Business Mailing Address Fax Number:
701-483-1001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
448 21ST ST W STE D1
Provider Second Line Business Practice Location Address:
THERAPY SOLUTIONS
Provider Business Practice Location Address City Name:
DICKINSON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58601-2647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-483-1000
Provider Business Practice Location Address Fax Number:
701-483-1001
Provider Enumeration Date:
08/30/2010

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:  2668 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041S0200X , with the licence number: 2668 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4560002242 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".