1194779942 NPI number — MS. CYNTHIA MARIE CHASE LCPC, LADC, CCS

Table of content: LAURA SOLLEY PHARMD (NPI 1447840483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194779942 NPI number — MS. CYNTHIA MARIE CHASE LCPC, LADC, CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHASE
Provider First Name:
CYNTHIA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCPC, LADC, CCS
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:
1194779942
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPSHAM
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04086-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-729-1803
Provider Business Mailing Address Fax Number:
207-777-8669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 BARIBEAU DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04011-3242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-522-2073
Provider Business Practice Location Address Fax Number:
207-729-1803
Provider Enumeration Date:
05/19/2006

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: 101YM0800X , with the licence number:  CC1723 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: LC1491 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 048265 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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