1639400864 NPI number — JUDITH LYNN RENWICK LCSW

Table of content: JUDITH LYNN RENWICK LCSW (NPI 1639400864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639400864 NPI number — JUDITH LYNN RENWICK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RENWICK
Provider First Name:
JUDITH
Provider Middle Name:
LYNN
Provider Name Prefix Text:
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:
1639400864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 966
Provider Second Line Business Mailing Address:
306 W 5TH AVE
Provider Business Mailing Address City Name:
NOME
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99762-0966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-443-4540
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 W 5TH AVE
Provider Second Line Business Practice Location Address:
NORTON SOUND HEALTH CORPORATION
Provider Business Practice Location Address City Name:
NOME
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99762-0966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-443-4540
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2010

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:  LCSW 887 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LCSW 887 . This is a "LCSW 887" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".