1972692168 NPI number — MRS. DIANE WINTHROP HAWKINS CLARK LISCW

Table of content: TIARA R HERNANDEZ (NPI 1932602190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972692168 NPI number — MRS. DIANE WINTHROP HAWKINS CLARK LISCW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAWKINS CLARK
Provider First Name:
DIANE
Provider Middle Name:
WINTHROP
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LISCW
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:
1972692168
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:
NEWBURYPORT COUNSELING GROUP 30 GREEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWBURYPORT
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 GREEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBURYPORT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-462-5646
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2006

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: 1041C0700X , with the licence number:  106112 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 338623 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: P05239 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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