1790896959 NPI number — MRS. DOROTHY TEBBUTT ALLEN MA LPA

Table of content: MRS. DOROTHY TEBBUTT ALLEN MA LPA (NPI 1790896959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790896959 NPI number — MRS. DOROTHY TEBBUTT ALLEN MA LPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
DOROTHY
Provider Middle Name:
TEBBUTT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA LPA
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:
1790896959
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 RAYBURN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAKE FOREST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27587
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-818-8249
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1725 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
WAKE FOREST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-556-6501
Provider Business Practice Location Address Fax Number:
919-556-4933
Provider Enumeration Date:
08/31/2006

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: 101YM0800X , with the licence number:  2045 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 046MH . This is a "NC HEALTH CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8375 . This is a "FIVE COUNTY MENTAL HEALTH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6107138 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com