1649552415 NPI number — MRS. STACEY E MEATH LICSW

Table of content: MEDORA JEAN HAMRICK CBS (NPI 1366074809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649552415 NPI number — MRS. STACEY E MEATH LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEATH
Provider First Name:
STACEY
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRENZ
Provider Other First Name:
STACEY
Provider Other Middle Name:
E
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:
1649552415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2705 BUNKER LAKE BLVD NW
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ANDOVER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55304-3784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-482-9598
Provider Business Mailing Address Fax Number:
612-235-6447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2705 BUNKER LAKE BLVD NW
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ANDOVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55304-3784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-482-9598
Provider Business Practice Location Address Fax Number:
612-235-6447
Provider Enumeration Date:
09/16/2011

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:  16432 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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