1528097201 NPI number — DR. VIRGINIA R EADES PHD., LPC

Table of content: DR. VIRGINIA R EADES PHD., LPC (NPI 1528097201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528097201 NPI number — DR. VIRGINIA R EADES PHD., LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EADES
Provider First Name:
VIRGINIA
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD., LPC
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:
1528097201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 CARMAN MEADOWS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63021-7174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-391-3310
Provider Business Mailing Address Fax Number:
636-391-3310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 CARMAN MEADOWS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALLWIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63021-7174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-391-3310
Provider Business Practice Location Address Fax Number:
636-391-3310
Provider Enumeration Date:
07/03/2006

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: 101YP2500X , with the licence number:  LPC 002232 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 122115 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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