1366402943 NPI number — MR. KEVIN J. OFFHAUS LCSW

Table of content: TRACY SCHRUNK LCSW (NPI 1194277202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366402943 NPI number — MR. KEVIN J. OFFHAUS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OFFHAUS
Provider First Name:
KEVIN
Provider Middle Name:
J.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

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:
1366402943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1140 MALLARD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANTECA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95337-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-835-1309
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 MALLARD CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANTECA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95337-6000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-835-1309
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2006

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: 1041C0700X , with the licence number:  25883 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 160743251-4 . This is a "PRISM" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9118369 . This is a "AETNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: UAW229284 U . This is a "VALUEOPTIONS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00030241501 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 647142 . This is a "VALUEOPTIONS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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