1811137904 NPI number — MARCIE M MAVRELES LCSW

Table of content: MARCIE M MAVRELES LCSW (NPI 1811137904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811137904 NPI number — MARCIE M MAVRELES LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAVRELES
Provider First Name:
MARCIE
Provider Middle Name:
M
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:
BURNS
Provider Other First Name:
MARCIE
Provider Other Middle Name:
ELYSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811137904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20970
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEYENNE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82003-7020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-633-7370
Provider Business Mailing Address Fax Number:
307-633-7382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 E 23RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82001-3748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
370-488-8238
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2009

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

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