1073692331 NPI number — MRS. SANDRA LEE SUPPAN MAED, LPCC

Table of content: MRS. SANDRA LEE SUPPAN MAED, LPCC (NPI 1073692331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073692331 NPI number — MRS. SANDRA LEE SUPPAN MAED, LPCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUPPAN
Provider First Name:
SANDRA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MAED, LPCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANGLIN
Provider Other First Name:
SANDRA
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073692331
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:
87 N CANTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AKRON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44305-3838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-794-4254
Provider Business Mailing Address Fax Number:
330-794-4262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 LOCUST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AKRON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44302-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-762-0591
Provider Business Practice Location Address Fax Number:
330-762-2242
Provider Enumeration Date:
11/06/2006

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: 101YP2500X , with the licence number:  E1885-S , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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