1235561762 NPI number — MOLLY HELENE HABERICHTER DPT

Table of content: MOLLY HELENE HABERICHTER DPT (NPI 1235561762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235561762 NPI number — MOLLY HELENE HABERICHTER DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HABERICHTER
Provider First Name:
MOLLY
Provider Middle Name:
HELENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIXEN
Provider Other First Name:
MOLLY
Provider Other Middle Name:
HELENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235561762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
516 MONTGOMERY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECORAH
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52101-2720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-794-0360
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 MONTGOMERY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECORAH
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52101-2720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-794-0360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2013

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: 225100000X , with the licence number:  005152 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34706 . This is a "BLUECROSS/BLUESHEILD IOWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0000619 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134142516 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 1134142516 . This is a "BLUE CROSS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1134142516 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 421470451 . This is a "MMSI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 421470451 . This is a "GUNDERSEN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 10134142516 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1134142516 . This is a "CARE PROVIDER NETWORK" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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