1992784276 NPI number — MRS. SUZANNE MICHELE KRESIAK LICSW

Table of content: MRS. SUZANNE MICHELE KRESIAK LICSW (NPI 1992784276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992784276 NPI number — MRS. SUZANNE MICHELE KRESIAK LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRESIAK
Provider First Name:
SUZANNE
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIS
Provider Other First Name:
SUZANNE
Provider Other Middle Name:
MICHELE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992784276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BOX 335
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTIS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-269-7466
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
73 RUSSELL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-667-3009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2006

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: 103T00000X , with the licence number:  110156 , 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: P08566 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".