1962619494 NPI number — MRS. MANDREA JEANETTE GODSEY BSCD MHPP

Table of content: MRS. MANDREA JEANETTE GODSEY BSCD MHPP (NPI 1962619494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962619494 NPI number — MRS. MANDREA JEANETTE GODSEY BSCD MHPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GODSEY
Provider First Name:
MANDREA
Provider Middle Name:
JEANETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BSCD MHPP
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:
1962619494
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
802 REAMS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOSNELL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72315-5719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-532-5953
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 BYRUM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLYTHEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72315-8033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-532-2600
Provider Business Practice Location Address Fax Number:
870-532-8494
Provider Enumeration Date:
05/16/2007

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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