1902802820 NPI number — DR. ROMA G DREVETS PH.D,LCPC,AAPS

Table of content: DR. ROMA G DREVETS PH.D,LCPC,AAPS (NPI 1902802820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902802820 NPI number — DR. ROMA G DREVETS PH.D,LCPC,AAPS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DREVETS
Provider First Name:
ROMA
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D,LCPC,AAPS
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:
1902802820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALINA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67402-2103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-823-1961
Provider Business Mailing Address Fax Number:
785-827-1401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 E IRON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALINA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67401-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-823-1961
Provider Business Practice Location Address Fax Number:
785-827-1401
Provider Enumeration Date:
06/24/2005

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: 101YA0400X , with the licence number:  598 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LCPC 179 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 119849 . This is a "BLUE CROSS BLUE SHIELD KS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".