1225216625 NPI number — MAIN STREET MENTAL HEALTH, PLLC

Table of content: (NPI 1225216625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225216625 NPI number — MAIN STREET MENTAL HEALTH, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET MENTAL HEALTH, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1225216625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 535
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEREDITH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03253-0535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-738-2445
Provider Business Mailing Address Fax Number:
603-279-7042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 CANAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEREDITH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03253-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-738-2445
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ST JEAN
Authorized Official First Name:
JOAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
603-738-2445

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 026459-23-08 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50Y011206NH01 . This is a "ANTHEM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 2152562 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3072631 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".