1063420644 NPI number — MRS. BRENDA VACTOR LCSW, PIP

Table of content: MRS. BRENDA VACTOR LCSW, PIP (NPI 1063420644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063420644 NPI number — MRS. BRENDA VACTOR LCSW, PIP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VACTOR
Provider First Name:
BRENDA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, PIP
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:
1063420644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3007 MEMORIAL PKWY SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35801-5393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-882-2003
Provider Business Mailing Address Fax Number:
256-705-4630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3007 MEMORIAL PKWY SW # SX
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35801-5393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-882-2003
Provider Business Practice Location Address Fax Number:
256-705-4630
Provider Enumeration Date:
08/03/2006

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 1692C , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1063420644 . This is a "ALLKIDS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063420644 . This is a "MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063420644 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063420644 . This is a "EPS- EXTENDED PSYCHIATRIC SERVICES" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063420644 . This is a "TRICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063420644 . This is a "BLUE ADVANTAGE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063420644 . This is a "MEDICAID (CROSSOVER)" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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