1417565110 NPI number — RACHEL RENEE SPURGEON LPC

Table of content: RACHEL RENEE SPURGEON LPC (NPI 1417565110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417565110 NPI number — RACHEL RENEE SPURGEON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPURGEON
Provider First Name:
RACHEL
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1417565110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YANTIS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75497-2727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-853-0144
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 W 5TH ST STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-4053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-201-7865
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2020

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: 101Y00000X , with the licence number:  78385 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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