1295833200 NPI number — SUZANNE P MOWRY SLP

Table of content: SUZANNE P MOWRY SLP (NPI 1295833200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295833200 NPI number — SUZANNE P MOWRY SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOWRY
Provider First Name:
SUZANNE
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
INGALLS
Provider Other First Name:
SUZANNE
Provider Other Middle Name:
PATRICIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.SC., S-LP(C)
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295833200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1599
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04402-1599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-404-8200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 TELCOM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-3072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-941-2850
Provider Business Practice Location Address Fax Number:
207-941-2852
Provider Enumeration Date:
09/21/2006

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: 235Z00000X , with the licence number:  SP3463 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP3953 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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