1225469513 NPI number — DR. ASHLEY MICHELE TANKERSLEY FAIRCLOTH D.P.T.

Table of content: JOEY REA PSY.D. (NPI 1962034579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225469513 NPI number — DR. ASHLEY MICHELE TANKERSLEY FAIRCLOTH D.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRCLOTH
Provider First Name:
ASHLEY
Provider Middle Name:
MICHELE TANKERSLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.T.
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:
1225469513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
318 NOTTOWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEARL RIVER
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70452-3804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1796 W CAUSEWAY APPROACH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANDEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70471-2955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-626-1671
Provider Business Practice Location Address Fax Number:
985-624-4984
Provider Enumeration Date:
12/11/2013

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: 225100000X , with the licence number:  08611 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08611 . This is a "LICENSE TO PRACTICE PHYSICAL THERAPY" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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