1063523397 NPI number — MRS. SHELLENE SUE CLEVERDON OT-L

Table of content: MRS. SHELLENE SUE CLEVERDON OT-L (NPI 1063523397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063523397 NPI number — MRS. SHELLENE SUE CLEVERDON OT-L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEVERDON
Provider First Name:
SHELLENE
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OT-L
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:
1063523397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-260-5692
Provider Business Mailing Address Fax Number:
406-849-6501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42468 JUNIPER SHORES LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-260-5692
Provider Business Practice Location Address Fax Number:
406-849-6501
Provider Enumeration Date:
08/31/2006

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: 225X00000X , with the licence number:  523 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0347293 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 660990 . This is a "BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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