1063566917 NPI number — ANITA MINKIN CSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063566917 NPI number — ANITA MINKIN CSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MINKIN
Provider First Name:
ANITA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERKOFSKY
Provider Other First Name:
ANITA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063566917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 EAST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWTUCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02860-6165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-457-5252
Provider Business Mailing Address Fax Number:
401-316-0439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 EAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAWTUCKET
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02860-6165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-457-5252
Provider Business Practice Location Address Fax Number:
401-316-0439
Provider Enumeration Date:
01/22/2007

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:  110026 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 1SW01289 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 308612 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 411510 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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