1184052201 NPI number — OLIVIA VALDEZ-MASSENA LCPC

Table of content: OLIVIA VALDEZ-MASSENA LCPC (NPI 1184052201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184052201 NPI number — OLIVIA VALDEZ-MASSENA LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALDEZ-MASSENA
Provider First Name:
OLIVIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MASSENA
Provider Other First Name:
OLIVIA
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:
1184052201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 N 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62702-6324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-525-1064
Provider Business Mailing Address Fax Number:
217-525-1651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 N COLLEGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62656-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-735-2272
Provider Business Practice Location Address Fax Number:
217-735-2342
Provider Enumeration Date:
10/29/2013

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: 101YP2500X , with the licence number:  180008848 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180008848 . This is a "LCPC LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".