1518054279 NPI number — MRS. AIMEE LYNN EBLEN P.T.

Table of content: MS. LAURA LOUESE PHELAN-SHAHIN MA, LMFT (NPI 1720213739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518054279 NPI number — MRS. AIMEE LYNN EBLEN P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EBLEN
Provider First Name:
AIMEE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1518054279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1810 MILLSIDE TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DACULA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30019-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-932-6612
Provider Business Mailing Address Fax Number:
678-377-2833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
318 W PIKE ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30045-3234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-314-1388
Provider Business Practice Location Address Fax Number:
678-377-2882
Provider Enumeration Date:
10/06/2006

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: 2251P0200X , with the licence number:  PT004663 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10037612 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00731882C . This is a "PEACHSTATE HEALTH PLAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00731882C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 307920 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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