1043972854 NPI number — POSITIVELY PSYCHED, PLLC

Table of content: (NPI 1043972854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043972854 NPI number — POSITIVELY PSYCHED, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POSITIVELY PSYCHED, PLLC
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:
1043972854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 N CATHERINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA GRANGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60525-5929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 N CATHERINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA GRANGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60525-5929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-244-2679
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LESTINA
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
630-244-2679

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1942667530 . This is a "CIGNA/PPO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1942667530 . This is a "BCBS/PPO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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