1457405607 NPI number — KERRY SHEAHAN CHRISTOPHER LPC

Table of content: KERRY SHEAHAN CHRISTOPHER LPC (NPI 1457405607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457405607 NPI number — KERRY SHEAHAN CHRISTOPHER LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHRISTOPHER
Provider First Name:
KERRY
Provider Middle Name:
SHEAHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COTTER
Provider Other First Name:
KERRY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457405607
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:
1011 N MAYFAIR RD
Provider Second Line Business Mailing Address:
304
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-3431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-453-8380
Provider Business Mailing Address Fax Number:
414-443-1635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 N MAYFAIR RD
Provider Second Line Business Practice Location Address:
304
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-3431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-453-8380
Provider Business Practice Location Address Fax Number:
414-443-1635
Provider Enumeration Date:
01/23/2007

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: 101YP2500X , with the licence number:  2959-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 43566200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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