1457630576 NPI number — MRS. KRISTA MARIE CONCHA MA,CCC,LSP

Table of content: RACHEL WAYNE (NPI 1124311345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457630576 NPI number — MRS. KRISTA MARIE CONCHA MA,CCC,LSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONCHA
Provider First Name:
KRISTA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA,CCC,LSP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HORAN
Provider Other First Name:
KRISTA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA,CCC,LSP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457630576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
574 ACLAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLSTON SPA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12020-3079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-581-8272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
61 GEYSER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARATOGA SPRINGS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12866-9018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-584-7699
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2011

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: 235Z00000X , with the licence number:  009086 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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