1205054244 NPI number — MRS. KELLY RENEE SCHAEFER SLP

Table of content: (NPI 1790942647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205054244 NPI number — MRS. KELLY RENEE SCHAEFER SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHAEFER
Provider First Name:
KELLY
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NIEMERG
Provider Other First Name:
KELLY
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205054244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1931 SOUTH 3RD STREET W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-829-6349
Provider Business Mailing Address Fax Number:
406-829-6349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1931 SOUTH 3RD STREET W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-829-6349
Provider Business Practice Location Address Fax Number:
406-829-6349
Provider Enumeration Date:
04/23/2007

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: 235Z00000X , 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)