1053493189 NPI number — SUSAN DIANE NIMROD LCPC

Table of content: SUSAN DIANE NIMROD LCPC (NPI 1053493189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053493189 NPI number — SUSAN DIANE NIMROD LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIMROD
Provider First Name:
SUSAN
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

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:
1053493189
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:
PO BOX 860513
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAWNEE MISSION
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-530-0158
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3515 S 4TH STREET
Provider Second Line Business Practice Location Address:
PROFESSIONAL ASSOCIATION
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-651-8415
Provider Business Practice Location Address Fax Number:
913-772-8580
Provider Enumeration Date:
10/19/2006

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: 101Y00000X , with the licence number:  213 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101Y00000X , with the licence number: 2000152681 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 33078027 . This is a "BCBS KANSAS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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