1245721158 NPI number — CHELSEA BREANNE VANDERFORD COUNSELOR INTERN

Table of content: (NPI 1871590364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245721158 NPI number — CHELSEA BREANNE VANDERFORD COUNSELOR INTERN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERFORD
Provider First Name:
CHELSEA
Provider Middle Name:
BREANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COUNSELOR INTERN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
CHELSEA
Provider Other Middle Name:
BREANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245721158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4400 E HIGHWAY 20 STE 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NICEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32578-7703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-897-7810
Provider Business Mailing Address Fax Number:
850-897-0032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 E HIGHWAY 20 STE 306
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578-7703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-897-7810
Provider Business Practice Location Address Fax Number:
850-897-0032
Provider Enumeration Date:
05/25/2018

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: 390200000X , with the licence number:  IMH16920 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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