1598774440 NPI number — MR. EARL LEROY BREWER LCPC

Table of content: MR. EARL LEROY BREWER LCPC (NPI 1598774440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598774440 NPI number — MR. EARL LEROY BREWER LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREWER
Provider First Name:
EARL
Provider Middle Name:
LEROY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
M

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:
1598774440
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 ROSEBUD STREET
Provider Second Line Business Mailing Address:
P.O. BOX 1176
Provider Business Mailing Address City Name:
FORSYTH
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59327-1176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-351-1820
Provider Business Mailing Address Fax Number:
406-346-1538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1075 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORSYTH
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-351-1820
Provider Business Practice Location Address Fax Number:
406-346-1538
Provider Enumeration Date:
08/07/2006

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:  1247 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 743280 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 257062 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".