1063477669 NPI number — CAROLYN M LOCKWOOD RPT

Table of content: CAROLYN M LOCKWOOD RPT (NPI 1063477669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063477669 NPI number — CAROLYN M LOCKWOOD RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOCKWOOD
Provider First Name:
CAROLYN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPT
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:
1063477669
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:
15 HOLLY FARM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MASHPEE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02649-3184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-477-4845
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
681 FALMOUTH RD
Provider Second Line Business Practice Location Address:
UNIT 24D
Provider Business Practice Location Address City Name:
MASHPEE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02649-3327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-477-5670
Provider Business Practice Location Address Fax Number:
508-539-1790
Provider Enumeration Date:
04/18/2006

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: 225100000X , with the licence number:  4167 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4167 . This is a "MA LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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