1366779811 NPI number — MRS. ERIN MICHELE ALDRICH GRAY M.F.T.

Table of content: MRS. ERIN MICHELE ALDRICH GRAY M.F.T. (NPI 1366779811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366779811 NPI number — MRS. ERIN MICHELE ALDRICH GRAY M.F.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALDRICH GRAY
Provider First Name:
ERIN
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.F.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALDRICH
Provider Other First Name:
ERIN
Provider Other Middle Name:
MICHELE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.F.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366779811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 SAGEBRUSH AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEYENNE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-514-2630
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3124 OLD FAITHFUL RD.
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-426-4798
Provider Business Practice Location Address Fax Number:
307-426-4799
Provider Enumeration Date:
11/04/2009

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: 106H00000X , with the licence number:  PMFT-235 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1619097755 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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