1225260813 NPI number — STREETERVILLE PSYCHOTHERAPY VAN ALPHEN & THAMES

Table of content: MR. JOHN MARTIN PUCKETT LMT (NPI 1396981908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225260813 NPI number — STREETERVILLE PSYCHOTHERAPY VAN ALPHEN & THAMES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STREETERVILLE PSYCHOTHERAPY VAN ALPHEN & THAMES
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:
1225260813
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
233 E ERIE ST
Provider Second Line Business Mailing Address:
SUITE 309
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60611-2926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-513-8505
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 E ERIE ST
Provider Second Line Business Practice Location Address:
SUITE 309
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60611-2926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-513-8505
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
VAN ALPHEN
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CLINICAL PSYCHOLOGY POST-DOC FELLOW
Authorized Official Telephone Number:
312-513-8505

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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