1558577510 NPI number — MRS. KELLY ELIZABETH PEARSON LCPC-C

Table of content: MRS. KELLY ELIZABETH PEARSON LCPC-C (NPI 1558577510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558577510 NPI number — MRS. KELLY ELIZABETH PEARSON LCPC-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEARSON
Provider First Name:
KELLY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCPC-C
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:
1558577510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92 TROUT BROOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIAVILLE
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04605-7160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-537-2077
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 WATER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLSWORTH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04605-2116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-667-5357
Provider Business Practice Location Address Fax Number:
207-667-0174
Provider Enumeration Date:
05/15/2007

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: 101YP2500X , with the licence number:  XL3131 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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