1710084405 NPI number — MOLLY FLEMING ELDRIDGE

Table of content: MOLLY FLEMING ELDRIDGE (NPI 1710084405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710084405 NPI number — MOLLY FLEMING ELDRIDGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELDRIDGE
Provider First Name:
MOLLY
Provider Middle Name:
FLEMING
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:
ELDRIDGE
Provider Other First Name:
MARY
Provider Other Middle Name:
REED
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710084405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 NORTHWEST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASTHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02642-2630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-255-8290
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 GRANITE STATE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREWSTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02631-2127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-240-5530
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2006

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:  1019514 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P05577 . This is a "BC/BS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 160861000 . This is a "MBC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1894901 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7729878 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 007445 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710084405 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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