1962769307 NPI number — MARY ELLEN STAHR LCSW LLC

Table of content: (NPI 1962769307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962769307 NPI number — MARY ELLEN STAHR LCSW LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY ELLEN STAHR LCSW LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1962769307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3653 CORTEZ RD W
Provider Second Line Business Mailing Address:
SUITE 110 H
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34210-3168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-758-1636
Provider Business Mailing Address Fax Number:
941-894-6224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3653 CORTEZ RD W
Provider Second Line Business Practice Location Address:
SUITE 110 H
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34210-3168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-758-1636
Provider Business Practice Location Address Fax Number:
941-894-6224
Provider Enumeration Date:
04/23/2012

Additional Information

Authorized Official

Authorized Official Last Name:
STAHR
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
941-758-1636

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1275 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0004477465 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 01128702 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 001713800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 257481 . This is a "MHN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: UAW065769 . This is a "VALUE OPTIONS/MILITARY ONE SOURCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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