1366565715 NPI number — SUSAN ZEKERT HUNDSDORFER OTR, CLVT

Table of content: SUSAN ZEKERT HUNDSDORFER OTR, CLVT (NPI 1366565715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366565715 NPI number — SUSAN ZEKERT HUNDSDORFER OTR, CLVT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUNDSDORFER
Provider First Name:
SUSAN
Provider Middle Name:
ZEKERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR, CLVT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZEKERT
Provider Other First Name:
SUSAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR, CLVT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366565715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 S 40TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80305-5905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-543-0669
Provider Business Mailing Address Fax Number:
303-494-0530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 S 40TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80305-5905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-543-0669
Provider Business Practice Location Address Fax Number:
303-494-0530
Provider Enumeration Date:
04/09/2007

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: 225X00000X , with the licence number:  CO HAS NO OT LICENSE , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 15297957 . This is a "WITHHOLD LIC-EYEONLIVING" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 665829002001 . This is a "UNEMP INS TAXIDEYEONLIVIN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 63180855 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 969623 . This is a "NATL BOARD FOR CERT IN OT" identifier . This identifiers is of the category "OTHER".




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