1578987822 NPI number — MEGAN MARIE PUDDY BCBA

Table of content: MEGAN MARIE PUDDY BCBA (NPI 1578987822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578987822 NPI number — MEGAN MARIE PUDDY BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUDDY
Provider First Name:
MEGAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATHY
Provider Other First Name:
MEGAN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578987822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1210 FOURIER DR
Provider Second Line Business Mailing Address:
SUITE #100
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53717-1969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-662-9327
Provider Business Mailing Address Fax Number:
608-662-9041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 FOURIER DR
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53717-1969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-662-9327
Provider Business Practice Location Address Fax Number:
608-662-9041
Provider Enumeration Date:
02/06/2014

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: 103K00000X , with the licence number:  79-140 , 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: 79-140 . This is a "STATE OF WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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