1831362839 NPI number — LORETTA PEARLE HENSON PHD., LP

Table of content: LORETTA PEARLE HENSON PHD., LP (NPI 1831362839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831362839 NPI number — LORETTA PEARLE HENSON PHD., LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENSON
Provider First Name:
LORETTA
Provider Middle Name:
PEARLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD., LP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LONGSDORF
Provider Other First Name:
LORETTA
Provider Other Middle Name:
PEARLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD., LP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831362839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 W CASCADE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVER FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54022-2222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-426-4967
Provider Business Mailing Address Fax Number:
715-426-0985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 W CASCADE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVER FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54022-2222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-426-4967
Provider Business Practice Location Address Fax Number:
715-426-0985
Provider Enumeration Date:
04/10/2008

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: 103TC0700X , with the licence number:  2135-057 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39766700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".