1417060930 NPI number — MRS. MELISSA M PEABODY P.T., CHT

Table of content: MRS. MELISSA M PEABODY P.T., CHT (NPI 1417060930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417060930 NPI number — MRS. MELISSA M PEABODY P.T., CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEABODY
Provider First Name:
MELISSA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T., CHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GURSKY
Provider Other First Name:
MELISSA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T., CHT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417060930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 ROUTE 88 W
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
BRICK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08724-3009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-840-8100
Provider Business Mailing Address Fax Number:
732-840-0559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1608 ROUTE 88 W
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
BRICK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08724-3009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-840-8100
Provider Business Practice Location Address Fax Number:
732-840-0559
Provider Enumeration Date:
08/17/2006

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: 225100000X , with the licence number:  2004018750 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 40QA00650800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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