1114195419 NPI number — LAKES REGION HEALTHCARE

Table of content: LESLIE DIANE WEED FONNER LICSW (NPI 1255513719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114195419 NPI number — LAKES REGION HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKES REGION HEALTHCARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1114195419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 509
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOMOSEEN
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05732-0509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-468-8755
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
49 CASTLETON MEADOWS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTLETON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05735-9011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-468-8755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BEAUREGARD
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
802-468-8755

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  0550030883 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9000153 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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