1356400329 NPI number — MS. ELLEN PATRICE SUMRALL BA PSYCHOLOGY

Table of content: MS. ELLEN PATRICE SUMRALL BA PSYCHOLOGY (NPI 1356400329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356400329 NPI number — MS. ELLEN PATRICE SUMRALL BA PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUMRALL
Provider First Name:
ELLEN
Provider Middle Name:
PATRICE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BA PSYCHOLOGY
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUMRALL
Provider Other First Name:
ELLEN
Provider Other Middle Name:
PATRICE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
BA PSYCHOLOGY
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1356400329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3855 LLEWELYN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-342-7337
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57 INDUSTRIAL PK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUCEDALE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-947-4274
Provider Business Practice Location Address Fax Number:
228-947-4275
Provider Enumeration Date:
12/06/2006

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00018214 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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