1275539223 NPI number — TERESA ELAINE BSULLAK L.C.S.W.

Table of content: TERESA ELAINE BSULLAK L.C.S.W. (NPI 1275539223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275539223 NPI number — TERESA ELAINE BSULLAK L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BSULLAK
Provider First Name:
TERESA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
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:
1275539223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
241 GREENHOUSE RD
Provider Second Line Business Mailing Address:
ATTN STEPHANIE BLACK
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24450-3717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-463-3141
Provider Business Mailing Address Fax Number:
540-464-4051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
241 GREENHOUSE RD
Provider Second Line Business Practice Location Address:
ATTN STEPHANIE BLACK
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24450-3717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-463-3141
Provider Business Practice Location Address Fax Number:
540-464-4051
Provider Enumeration Date:
06/23/2005

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: 1041C0700X , with the licence number:  0904005147 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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