1497907174 NPI number — MS. CLAUDETTE M IDIGO LCSW

Table of content: MS. CLAUDETTE M IDIGO LCSW (NPI 1497907174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497907174 NPI number — MS. CLAUDETTE M IDIGO LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IDIGO
Provider First Name:
CLAUDETTE
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
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:
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:
1497907174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 SAN MARINO CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-1435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-428-1728
Provider Business Mailing Address Fax Number:
678-523-2351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 SAN MARINO CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-1435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-723-4448
Provider Business Practice Location Address Fax Number:
678-528-2351
Provider Enumeration Date:
10/14/2008

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:  CSW004018 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CSW0004018 . This is a "PROFESSIONAL STATE LICENSURE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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