1184775694 NPI number — MS. KATHERINE HUDSPETH MAYNARD MS

Table of content: MS. KATHERINE HUDSPETH MAYNARD MS (NPI 1184775694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184775694 NPI number — MS. KATHERINE HUDSPETH MAYNARD MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYNARD
Provider First Name:
KATHERINE
Provider Middle Name:
HUDSPETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS
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:
1184775694
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:
703 BRAND FARM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05403-7542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-862-2182
Provider Business Mailing Address Fax Number:
802-654-7601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 W CANAL ST
Provider Second Line Business Practice Location Address:
SUITE C2
Provider Business Practice Location Address City Name:
WINOOSKI
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05404-2131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-654-7600
Provider Business Practice Location Address Fax Number:
802-654-7601
Provider Enumeration Date:
01/13/2007

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: 101YA0400X , with the licence number:  000158 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YM0800X , with the licence number: 068-0000481 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 208405 . This is a "CIGNA BEHAVIORAL HEALTH C" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1008141 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 58349 . This is a "BCBS OF VT" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 61225 . This is a "MVP HEALTH CARE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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