1922005693 NPI number — MRS. ELLEN H WEILAND L.C.S.W.

Table of content: MRS. ELLEN H WEILAND L.C.S.W. (NPI 1922005693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922005693 NPI number — MRS. ELLEN H WEILAND L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEILAND
Provider First Name:
ELLEN
Provider Middle Name:
H
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
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:
1922005693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/21/2006
NPI Reactivation Date:
03/29/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 851
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97535-0851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-326-8989
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97501-2746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-326-8989
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2005

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: 1041C0700X , with the licence number:  L2150 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 99945 . This is a "JACKSON COUNTY MENTAL HEA" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 858186000 . This is a "BC BS - L.C.S.W." identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 181580 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 317191 . This is a "PBH" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: J6586 . This is a "PACIFIC SOURCE HEALTH PN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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