1497904312 NPI number — LAKE MARTIN FAMILY THERAPY, LLC

Table of content: (NPI 1497904312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497904312 NPI number — LAKE MARTIN FAMILY THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE MARTIN FAMILY THERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1497904312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 911
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDER CITY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35011-0911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-625-9514
Provider Business Mailing Address Fax Number:
256-825-6418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
393 GREEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDER CITY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35010-1407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-625-9514
Provider Business Practice Location Address Fax Number:
256-825-6418
Provider Enumeration Date:
09/16/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
MEMBER/OWNER
Authorized Official Telephone Number:
256-625-9514

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  2121C , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: L 299 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: L 299 . This is a "ALABAMA BOARD OF EXAMINERS IN MARRIAGE & FAMILY THERAPY" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 2121C . This is a "STATE OF ALABAMA BOARD OF SOCIAL WORK EXMAINERS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".