1457457251 NPI number — DR. SANDRA L NOVAK PSY.D.

Table of content: DR. SANDRA L NOVAK PSY.D. (NPI 1457457251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457457251 NPI number — DR. SANDRA L NOVAK PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOVAK
Provider First Name:
SANDRA
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
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:
1457457251
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
355TH MDG/OMRS - MENTAL HEALTH CLINIC
Provider Second Line Business Mailing Address:
5427 E MADERA ST, BLDG 4339
Provider Business Mailing Address City Name:
DAVIS-MONTHAN AFB
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-228-4357
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7219 N LITCHFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUKE AFB
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85309-1529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-859-7579
Provider Business Practice Location Address Fax Number:
623-856-4433
Provider Enumeration Date:
09/16/2006

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: 103TC0700X , with the licence number:  071008889 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY-005303 , 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)

  • Identifier: F400210383 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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