1053337592 NPI number — MS. PAMELA DEMOSTHENES RUSTIN LCSW, CP CAC II

Table of content: MS. PAMELA DEMOSTHENES RUSTIN LCSW, CP CAC II (NPI 1053337592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053337592 NPI number — MS. PAMELA DEMOSTHENES RUSTIN LCSW, CP CAC II

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSTIN
Provider First Name:
PAMELA
Provider Middle Name:
DEMOSTHENES
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, CP CAC II
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:
1053337592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4300 SAPPHIRE CT
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27834-9079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-830-7561
Provider Business Mailing Address Fax Number:
252-413-0932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WIESBADEN ARMY SUBSTANCE ABUSE PROGRAM
Provider Second Line Business Practice Location Address:
UNIT 29623
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
496117051710
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2006

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:  C006055 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 06223 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 64648 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: C006055 . This is a "NC BOARD OF SOCIAL WORK" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 06223 . This is a "SC BOARD OF SOCIAL WORK" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".