1063448694 NPI number — MS. BRIDGET LEICESTER LICSW

Table of content: MS. BRIDGET LEICESTER LICSW (NPI 1063448694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063448694 NPI number — MS. BRIDGET LEICESTER LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEICESTER
Provider First Name:
BRIDGET
Provider Middle Name:
Provider Name Prefix Text:
MS.
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:
1063448694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROCTORSVILLE
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05153-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-226-7450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 MAHONEY AVE
Provider Second Line Business Practice Location Address:
PSYCHIATRY & PSYCHOTHERAPY ASSOCS
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-775-2581
Provider Business Practice Location Address Fax Number:
802-775-3395
Provider Enumeration Date:
06/24/2006

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:  089-0000928 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: R042998-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 01562610 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59551 . This is a "BL CR BL SH OF VT" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1009403 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 412173 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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