1821531104 NPI number — UPTOWN NOLA PSYCH LLC

Table of content: (NPI 1821531104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821531104 NPI number — UPTOWN NOLA PSYCH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UPTOWN NOLA PSYCH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1821531104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1315 WALNUT ST
Provider Second Line Business Mailing Address:
SUITE 805
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-4719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-805-9445
Provider Business Mailing Address Fax Number:
215-545-8496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7611 MAPLE ST
Provider Second Line Business Practice Location Address:
SUITE B3
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70118-5068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-232-7338
Provider Business Practice Location Address Fax Number:
504-323-1992
Provider Enumeration Date:
11/18/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BURKE
Authorized Official First Name:
LEO
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MEDICAL PSYCHOLOGIST
Authorized Official Telephone Number:
504-232-7338

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1375 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X , with the licence number: 1375 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP0016X , with the licence number: MP304056 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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