1528727831 NPI number — NICOLE WALKSALONG

Table of content: NICOLE WALKSALONG (NPI 1528727831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528727831 NPI number — NICOLE WALKSALONG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKSALONG
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KEEHNER
Provider Other First Name:
NICOLE
Provider Other Middle Name:
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:
1528727831
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
974 PAYTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARDIN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59034-2405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-850-0956
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
974 PAYTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARDIN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59034-2405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-850-0956
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2021

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: 104100000X , with the licence number:  LCSW-53250 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW-53250 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LCSW-53250 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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