1538211701 NPI number — JAN M SANFORD LPC-MH, QMHP, LSWA

Table of content: JAN M SANFORD LPC-MH, QMHP, LSWA (NPI 1538211701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538211701 NPI number — JAN M SANFORD LPC-MH, QMHP, LSWA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANFORD
Provider First Name:
JAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC-MH, QMHP, LSWA
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:
1538211701
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:
309 2ND AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57201-3621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-886-6321
Provider Business Mailing Address Fax Number:
605-886-6306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 2ND AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57201-3621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-886-6321
Provider Business Practice Location Address Fax Number:
605-886-6306
Provider Enumeration Date:
01/17/2007

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: 101YM0800X , with the licence number:  LPC-MH 2087 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC-MH 2087 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 104100000X , with the licence number: LSWA 2146 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 154887500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20202 . This is a "SIOUX VALLEY HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4997066 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9173854 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 11350 . This is a "MIDLANDS CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 46045 . This is a "AVERA HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 6575620 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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