1033171061 NPI number — MS. SUSAN ANN TANGIRES LCPC LCADC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033171061 NPI number — MS. SUSAN ANN TANGIRES LCPC LCADC

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

TANGIRES

Provider First Name:

SUSAN

Provider Middle Name:

ANN

Provider Name Prefix Text:

MS.

Provider Name Suffix Text:

Provider Credential Text:

LCPC LCADC

Provider Gender Code:

F

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:

1033171061

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/14/2016

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

3134 CHATHAM CT

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ELLICOTT CITY

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21042-2410

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

410-465-8448

Provider Business Mailing Address Fax Number:

410-744-9423

Provider First Line Business Practice Location Address:

800 INGLESIDE AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CATONSVILLE

Provider Business Practice Location Address State Name:

MD

Provider Business Practice Location Address Postal Code:

21228-1722

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

410-744-5937

Provider Business Practice Location Address Fax Number:

410-744-9423

Provider Enumeration Date:

04/05/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 101YA0400X , with the licence number:  LCA343 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 101YP2500X , with the licence number: LC1260 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0089 . This is a "BS FEDERAL GROUP S003" identifier . This identifiers is of the category "OTHER".
• Identifier: 328196 . This is a "MHN AND TRICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 487506 . This is a "VALUE OPTIONS GREAT WEST" identifier . This identifiers is of the category "OTHER".
• Identifier: 11554503 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
• Identifier: 721298000 . This is a "MAGELLAN BEHAVIORAL HEALT" identifier . This identifiers is of the category "OTHER".
• Identifier: 522229157 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
• Identifier: 2124028 . This is a "MAMSI UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 333404000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 7284589 . This is a "AETNA BEHAVIORAL HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 100072697 . This is a "APS" identifier . This identifiers is of the category "OTHER".
• Identifier: 63662901 . This is a "BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".