1518473966 NPI number — MRS. KIRSTEN LYNNE MASRELIAN BCBA

Table of content: MRS. KIRSTEN LYNNE MASRELIAN BCBA (NPI 1518473966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518473966 NPI number — MRS. KIRSTEN LYNNE MASRELIAN BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASRELIAN
Provider First Name:
KIRSTEN
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONRAD
Provider Other First Name:
KIRSTEN
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518473966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2073 LAWRENCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DE PERE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54115-9106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-351-3027
Provider Business Mailing Address Fax Number:
920-351-3043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2073 LAWRENCE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DE PERE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-351-3027
Provider Business Practice Location Address Fax Number:
920-351-3043
Provider Enumeration Date:
12/21/2017

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: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100049431 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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