1871653584 NPI number — LISA D BEVERIDGE LSW

Table of content: LISA D BEVERIDGE LSW (NPI 1871653584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871653584 NPI number — LISA D BEVERIDGE LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEVERIDGE
Provider First Name:
LISA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSW
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:
1871653584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1830
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLENTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18105-1830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-862-3193
Provider Business Mailing Address Fax Number:
484-664-7659

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14351 KUTZTOWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLEETWOOD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19522-9273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-944-8800
Provider Business Practice Location Address Fax Number:
610-944-8213
Provider Enumeration Date:
12/11/2006

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: 104100000X , with the licence number:  SW122833 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: CW018756 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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