1679861462 NPI number — MARCELLA EILEEN FREEMAN LCSW

Table of content: MARCELLA EILEEN FREEMAN LCSW (NPI 1679861462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679861462 NPI number — MARCELLA EILEEN FREEMAN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREEMAN
Provider First Name:
MARCELLA
Provider Middle Name:
EILEEN
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:
WALKER
Provider Other First Name:
MARCELLA
Provider Other Middle Name:
EILEEN
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:
1679861462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10970
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33733-0970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-327-7656
Provider Business Mailing Address Fax Number:
727-322-2110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4024 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-327-7656
Provider Business Practice Location Address Fax Number:
727-322-2110
Provider Enumeration Date:
07/14/2011

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:  SW11437 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009082400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com