1306098165 NPI number — SUZANNE MARIE GLEASON LSW

Table of content: SUZANNE MARIE GLEASON LSW (NPI 1306098165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306098165 NPI number — SUZANNE MARIE GLEASON LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLEASON
Provider First Name:
SUZANNE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSW
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:
1306098165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4854 HILTON PARKWAY
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-600-1088
Provider Business Mailing Address Fax Number:
719-599-4693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4854 HILTON PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-600-1088
Provider Business Practice Location Address Fax Number:
719-599-4693
Provider Enumeration Date:
10/10/2008

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: 101YM0800X , with the licence number:  9674 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 680205778 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9674 . This is a "COLORADO REGISTRATION (DORA)" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 6802057778 . This is a "MICHIGAN DEPARTMENT OF COMMUNITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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