1871520304 NPI number — SUE ELLEN GOSTANIAN LPC

Table of content: DR. MICHAEL S REILLY DDS (NPI 1447236963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871520304 NPI number — SUE ELLEN GOSTANIAN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOSTANIAN
Provider First Name:
SUE
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1871520304
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 OLD NEW MILFORD RD
Provider Second Line Business Mailing Address:
2F
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06804-2426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-775-2583
Provider Business Mailing Address Fax Number:
203-775-2863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 OLD NEW MILFORD RD
Provider Second Line Business Practice Location Address:
2F
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06804-2426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-775-2583
Provider Business Practice Location Address Fax Number:
203-775-2863
Provider Enumeration Date:
06/28/2006

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: 101YP2500X , with the licence number:  000111 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0004332774 . This is a "AETNA HEALTH CARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1065880000 . This is a "MAGELLAN HEALTH CARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P1093372 . This is a "OXFORD HEALTH CARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 018638 . This is a "MHN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 240000111CT01 . This is a "ABH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9374982 . This is a "PHCS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0102904 . This is a "GHI" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 132249 . This is a "VALUE OPTIONS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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