1104175280 NPI number — MRS. CHELSEA BETH PHILLIPS CLAYBROOK PTA

Table of content: MRS. CHELSEA BETH PHILLIPS CLAYBROOK PTA (NPI 1104175280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104175280 NPI number — MRS. CHELSEA BETH PHILLIPS CLAYBROOK PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS CLAYBROOK
Provider First Name:
CHELSEA
Provider Middle Name:
BETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
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:
1104175280
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 SOUTH 74TH ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-478-5577
Provider Business Mailing Address Fax Number:
479-478-5560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 SOUTH 74TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-478-5577
Provider Business Practice Location Address Fax Number:
479-478-5560
Provider Enumeration Date:
09/05/2012

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: 225200000X , with the licence number:  PTA 2617 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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