1831410711 NPI number — THERESA M BURRITT LPCMH

Table of content: THERESA M BURRITT LPCMH (NPI 1831410711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831410711 NPI number — THERESA M BURRITT LPCMH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURRITT
Provider First Name:
THERESA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCMH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REYNOLDS
Provider Other First Name:
THERESA
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPCMH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831410711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
156 S STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19901-7314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-674-2380
Provider Business Mailing Address Fax Number:
302-674-1299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
156 S STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19901-7314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-674-2380
Provider Business Practice Location Address Fax Number:
302-674-1299
Provider Enumeration Date:
06/15/2010

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:  PC0000405 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PC-0000405 . This is a "STATE OF DELAWARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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