1043398571 NPI number — MRS. EVELYN ANN O LEARY BENNETT RN LCPC

Table of content: MRS. EVELYN ANN O LEARY BENNETT RN LCPC (NPI 1043398571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043398571 NPI number — MRS. EVELYN ANN O LEARY BENNETT RN LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O LEARY BENNETT
Provider First Name:
EVELYN
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O LEARY
Provider Other First Name:
EVY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN LCPC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1043398571
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:
127 N HIGGINS AVE RM 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59802-4457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-549-2625
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
127 N HIGGINS AVE RM 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59802-4457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-549-2625
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2006

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: 101YP2500X , with the licence number:  484LCPC , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 163WR0400X , with the licence number: 09268 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 0253657 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13005657 . This is a "MT ST FUND PAYEE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 74903 . This is a "BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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