1700164845 NPI number — MRS. MARTA JEANETTE VANN MS LPC CANDIDATE

Table of content: MRS. MARTA JEANETTE VANN MS LPC CANDIDATE (NPI 1700164845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700164845 NPI number — MRS. MARTA JEANETTE VANN MS LPC CANDIDATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANN
Provider First Name:
MARTA
Provider Middle Name:
JEANETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS LPC CANDIDATE
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:
1700164845
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 SOUTH MUSKOGEE STREET
Provider Second Line Business Mailing Address:
HARTSELL PSYCHOLOGICAL SERVICES
Provider Business Mailing Address City Name:
TAHLEQUAH
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-458-5757
Provider Business Mailing Address Fax Number:
918-458-5755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 SOUTH MUSKOGEE STREET
Provider Second Line Business Practice Location Address:
HARTSELL PSYCHOLOGICAL SERVICES
Provider Business Practice Location Address City Name:
TAHLEQUAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-458-5757
Provider Business Practice Location Address Fax Number:
918-458-5755
Provider Enumeration Date:
07/22/2011

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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