1487194213 NPI number — MARIETTA WHITTLESEY LPC LLC

Table of content: (NPI 1487194213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487194213 NPI number — MARIETTA WHITTLESEY LPC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIETTA WHITTLESEY LPC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1487194213
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCRAMDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12503-0125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-435-2777
Provider Business Mailing Address Fax Number:
860-435-2777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
184 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEVILLE
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06039-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-435-2777
Provider Business Practice Location Address Fax Number:
860-435-2777
Provider Enumeration Date:
02/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WHITTLESEY
Authorized Official First Name:
MARIETTA
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-435-2777

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  2678 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008057031 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com