1184732794 NPI number — MS. MARY ANN MERNAUGH LPC

Table of content: HOLLY MARIE SESOCK (NPI 1649901778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184732794 NPI number — MS. MARY ANN MERNAUGH LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERNAUGH
Provider First Name:
MARY ANN
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DIMATTIO
Provider Other First Name:
MARY ANN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184732794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2578
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATESVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72503-2578
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-994-2106
Provider Business Mailing Address Fax Number:
870-994-7868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714-A ASHFLAT DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHFLAT AR
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-994-2106
Provider Business Practice Location Address Fax Number:
870-994-7868
Provider Enumeration Date:
08/25/2006

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: 101YM0800X , with the licence number:  P0507049 , 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)

  • Identifier: 5Y528 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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