1053902569 NPI number — DIVINE MENTAL HEALTH TREATMENT

Table of content: GEOFFREY E. FOSTER DPM (NPI 1326126400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053902569 NPI number — DIVINE MENTAL HEALTH TREATMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE MENTAL HEALTH TREATMENT
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:
6
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:
1053902569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27 CARPENTER AVE STE 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10940-2401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-238-8853
Provider Business Mailing Address Fax Number:
646-619-4083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 CARPENTER AVE STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10940-2401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
452-388-8538
Provider Business Practice Location Address Fax Number:
646-619-4083
Provider Enumeration Date:
01/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MAYERS
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
PSYCHIATRIC NURSE PRACTITIONER
Authorized Official Telephone Number:
845-238-8853

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04672304 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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