1578615449 NPI number — MS. WANDA RUTH ECKERSLEY LPC

Table of content: MS. WANDA RUTH ECKERSLEY LPC (NPI 1578615449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578615449 NPI number — MS. WANDA RUTH ECKERSLEY LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ECKERSLEY
Provider First Name:
WANDA
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MS.
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:
1578615449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 924
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRIENDSWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77549-0924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-992-3300
Provider Business Mailing Address Fax Number:
281-996-0261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2006 BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
PEARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77581-5564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-992-3300
Provider Business Practice Location Address Fax Number:
281-996-0261
Provider Enumeration Date:
01/18/2007

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: 101YP2500X , with the licence number:  17422 , 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)

  • Identifier: 1490393-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6070 LC . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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