1235546417 NPI number — SPECTRUM BEHAVIORAL CONSULTING LLC

Table of content: (NPI 1235546417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235546417 NPI number — SPECTRUM BEHAVIORAL CONSULTING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM BEHAVIORAL CONSULTING LLC
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:
1235546417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1109 FERN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUFFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23434-2547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-535-1723
Provider Business Mailing Address Fax Number:
844-719-9024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1109 FERN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23434-2547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-535-1723
Provider Business Practice Location Address Fax Number:
844-719-9024
Provider Enumeration Date:
07/19/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SHEPSKI
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
FEARN
Authorized Official Title or Position:
PRESIDENT/BCBA
Authorized Official Telephone Number:
757-535-1723

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  0134000061 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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