1043500176 NPI number — DR. PATRICIA A CHESLOCK, PC

Table of content: JAMIE ALEXANDRIA BOUSNAKIS OTR/L (NPI 1013177740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043500176 NPI number — DR. PATRICIA A CHESLOCK, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. PATRICIA A CHESLOCK, PC
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:
1043500176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 SARAH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STROUDSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18360-1738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-421-7100
Provider Business Mailing Address Fax Number:
570-420-1248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 SARAH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STROUDSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18360-1738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-421-7100
Provider Business Practice Location Address Fax Number:
570-420-1248
Provider Enumeration Date:
04/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CHESLOCK
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST/ OWNER
Authorized Official Telephone Number:
570-421-7100

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X , with the licence number:  PS016434 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 82336 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 002050173 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 002050173 . This is a "FPLIC TRADITIONAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 102219041 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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