1124146717 NPI number — DR. DIANA HEARST IKEDA PH.D.

Table of content: ERICA PATRINA SCALES (NPI 1497623805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124146717 NPI number — DR. DIANA HEARST IKEDA PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEARST IKEDA
Provider First Name:
DIANA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1124146717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2628
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUXBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02331-2628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-934-6390
Provider Business Mailing Address Fax Number:
781-934-9991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 TREMONT ST
Provider Second Line Business Practice Location Address:
SUITE 12 A
Provider Business Practice Location Address City Name:
DUXBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02332-5310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-934-6390
Provider Business Practice Location Address Fax Number:
781-934-9991
Provider Enumeration Date:
03/26/2007

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: 101YA0400X , with the licence number:  6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TA0400X , with the licence number: 6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TA0700X , with the licence number: 6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TB0200X , with the licence number: 6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: 6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X , with the licence number: 6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0000X , with the licence number: 6917 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: W05211 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: W05611 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 407109 . This is a "TUFTS BEHAVIORAL HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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