1306905252 NPI number — MS. SALLY INDEPENDENCE BOWIE LICSW

Table of content: MS. SALLY INDEPENDENCE BOWIE LICSW (NPI 1306905252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306905252 NPI number — MS. SALLY INDEPENDENCE BOWIE LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWIE
Provider First Name:
SALLY
Provider Middle Name:
INDEPENDENCE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
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:
1306905252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 BARBERRY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02421-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-674-9124
Provider Business Mailing Address Fax Number:
781-674-9126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 MUZZEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02421-5222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-674-9124
Provider Business Practice Location Address Fax Number:
781-674-9126
Provider Enumeration Date:
12/07/2006

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: 104100000X , with the licence number:  102804 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P02455 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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