1528194040 NPI number — MRS. LARAINE DE BLONDE HETZER MSW LDCSW R

Table of content: MRS. LARAINE DE BLONDE HETZER MSW LDCSW R (NPI 1528194040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528194040 NPI number — MRS. LARAINE DE BLONDE HETZER MSW LDCSW R

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HETZER
Provider First Name:
LARAINE
Provider Middle Name:
DE BLONDE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW LDCSW R
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:
1528194040
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 SATTERLEE PLACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAPPINGERS FALLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12590-2625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-298-8070
Provider Business Mailing Address Fax Number:
845-462-3310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 SATTERLEE PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAPPINGERS FALLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12590-2625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-298-8070
Provider Business Practice Location Address Fax Number:
845-462-3310
Provider Enumeration Date:
02/26/2007

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: 1041C0700X , with the licence number:  0384431 , 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)

  • Identifier: 02261392 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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