1396801247 NPI number — MRS. MONIQUE PETRINE SMITALA LCSW

Table of content: MRS. MONIQUE PETRINE SMITALA LCSW (NPI 1396801247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396801247 NPI number — MRS. MONIQUE PETRINE SMITALA LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITALA
Provider First Name:
MONIQUE
Provider Middle Name:
PETRINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITALA
Provider Other First Name:
NIKKI
Provider Other Middle Name:
PETRINE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1396801247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N3189 ELTON SOUTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELTON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54430-9725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-882-3344
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 CLERMONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANTIGO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54409-1942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-842-5577
Provider Business Practice Location Address Fax Number:
715-845-8483
Provider Enumeration Date:
12/28/2006

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: 1041C0700X , with the licence number:  1703-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39276900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com