1699147215 NPI number — KELLIE BIBB

Table of content: MR. BRIAN S ABBOTT MFT (NPI 1740299015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699147215 NPI number — KELLIE BIBB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIBB
Provider First Name:
KELLIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIDENER
Provider Other First Name:
KELLIE
Provider Other Middle Name:
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:
1699147215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62708-3428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-588-2600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3220 ATLANTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62707-8801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-588-2600
Provider Business Practice Location Address Fax Number:
217-862-0202
Provider Enumeration Date:
10/22/2015

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: 363LF0000X , with the licence number:  209013401 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 277.000110 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 041.382679 . This is a "RN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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