1447441316 NPI number — MRS. PHILOMENA BRIDGET NOWAK MS LCPC CRC

Table of content: MRS. PHILOMENA BRIDGET NOWAK MS LCPC CRC (NPI 1447441316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447441316 NPI number — MRS. PHILOMENA BRIDGET NOWAK MS LCPC CRC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOWAK
Provider First Name:
PHILOMENA
Provider Middle Name:
BRIDGET
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS LCPC CRC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NOWAK
Provider Other First Name:
BRIDGET
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS LCPC CRC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1447441316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 818
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOKENA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-479-8977
Provider Business Mailing Address Fax Number:
708-479-8987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9405 BORMET
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
MOKENA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-479-8977
Provider Business Practice Location Address Fax Number:
708-479-8987
Provider Enumeration Date:
08/06/2007

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: 225C00000X , with the licence number:  00005014 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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