1336578996 NPI number — KIRBY GARDNER LCMHC

Table of content: KIRBY GARDNER LCMHC (NPI 1336578996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336578996 NPI number — KIRBY GARDNER LCMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
KIRBY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOOTE
Provider Other First Name:
KIRBY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CAGS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336578996
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 SWIFT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRIMACK
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03054-4840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-714-1725
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 MAIN ST
Provider Second Line Business Practice Location Address:
300
Provider Business Practice Location Address City Name:
NASHUA
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03060-2720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-547-2909
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2013

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: 101YM0800X , with the licence number:  988 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3088807 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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