1255429122 NPI number — MS. GWENDOLYN G GARRETT MAOTR

Table of content: MS. GWENDOLYN G GARRETT MAOTR (NPI 1255429122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255429122 NPI number — MS. GWENDOLYN G GARRETT MAOTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARRETT
Provider First Name:
GWENDOLYN
Provider Middle Name:
G
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MAOTR
Provider Gender Code:
F

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:
1255429122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
771 PILOT HOUSE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23606-1990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-873-2302
Provider Business Mailing Address Fax Number:
757-873-2306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 OYSTER POINT RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23602-6014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-269-0430
Provider Business Practice Location Address Fax Number:
757-269-0432
Provider Enumeration Date:
10/10/2006

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: 225X00000X , with the licence number:  0119001200 , 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)

  • Identifier: 1255429122 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7150820 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1154551935 . This is a "BCBS (OCCUPATIONAL THERAPY)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00733181 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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