1275903312 NPI number — SUSAN K ELEESON INC

Table of content: (NPI 1275903312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275903312 NPI number — SUSAN K ELEESON INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUSAN K ELEESON INC
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:
1275903312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47143 299TH ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERESFORD
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-351-5826
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47143 299TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERESFORD
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-351-5826
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ELEESON
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
KRISTINE
Authorized Official Title or Position:
CEO/LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
605-351-5826

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  399 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1568417657 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: S107742 . This is a "PTAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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