1992818439 NPI number — DEER CREEK PSYCHOLOGICAL ASSOCIATES, PA

Table of content: COLLEEN MCGAULEY NURSE PRACTITIONER (NPI 1144872060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992818439 NPI number — DEER CREEK PSYCHOLOGICAL ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEER CREEK PSYCHOLOGICAL ASSOCIATES, PA
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:
1992818439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST THETFORD
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05043-0266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-785-2903
Provider Business Mailing Address Fax Number:
802-785-2631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 LYME RD
Provider Second Line Business Practice Location Address:
SUITE 202A
Provider Business Practice Location Address City Name:
HANOVER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03755-1219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-785-2543
Provider Business Practice Location Address Fax Number:
802-785-2631
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHIN
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
603-643-9252

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TB0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 062-19470 . This is a "VT BLUECROSS BLUESHIELD" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 50Y303300VT01 . This is a "ANTHEM BCBS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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