1437368081 NPI number — MRS. ELLEN CUSACK VIMMERSTEDT M.A.

Table of content: MRS. ELLEN CUSACK VIMMERSTEDT M.A. (NPI 1437368081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437368081 NPI number — MRS. ELLEN CUSACK VIMMERSTEDT M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIMMERSTEDT
Provider First Name:
ELLEN
Provider Middle Name:
CUSACK
Provider Name Prefix Text:
MRS.
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:
1437368081
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:
301 E BETHANY HOME RD
Provider Second Line Business Mailing Address:
C-296
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85012-1263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-266-8442
Provider Business Mailing Address Fax Number:
602-588-9618

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 E BETHANY HOME RD
Provider Second Line Business Practice Location Address:
C-296
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85012-1263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-266-8442
Provider Business Practice Location Address Fax Number:
602-588-9618
Provider Enumeration Date:
05/21/2007

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 , with the licence number:  LPC-1266 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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