1629587456 NPI number — RADFORD UNIVERSITY

Table of content: IAN BRODERICK GOUGH MS, LPC (NPI 1568134625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629587456 NPI number — RADFORD UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADFORD UNIVERSITY
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:
INFANT & TODDLER CONNECTION OF THE NEW RIVER VALLEY - RU
Provider Other Organization Name Type Code:
5
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:
1629587456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 7006
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RADFORD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-831-7529
Provider Business Mailing Address Fax Number:
540-831-6908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RADFORD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-831-7529
Provider Business Practice Location Address Fax Number:
540-831-6908
Provider Enumeration Date:
09/25/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PIERSON
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
SYSTEM MANAGER
Authorized Official Telephone Number:
540-831-7529

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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