1417421892 NPI number — AH-MIRAH DENISE LUCILLE RICHMOND M.A.

Table of content: AH-MIRAH DENISE LUCILLE RICHMOND M.A. (NPI 1417421892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417421892 NPI number — AH-MIRAH DENISE LUCILLE RICHMOND M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHMOND
Provider First Name:
AH-MIRAH
Provider Middle Name:
DENISE LUCILLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
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:
1417421892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 N MERIDIAN ST # V278
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWBERG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97132-2697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
672 NE EVANS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-434-7523
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2019

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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