1588000723 NPI number — COLLEEN ELIZABETH NULL LISW-S

Table of content: COLLEEN ELIZABETH NULL LISW-S (NPI 1588000723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588000723 NPI number — COLLEEN ELIZABETH NULL LISW-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NULL
Provider First Name:
COLLEEN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZYCHOWICZ
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
ELIZABETH
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:
1588000723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3355 GLENDALE AVE FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43614-2426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-383-3815
Provider Business Mailing Address Fax Number:
419-383-2930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 E MEDICAL LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-383-3815
Provider Business Practice Location Address Fax Number:
419-383-2930
Provider Enumeration Date:
05/15/2013

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:  C009463 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: I.1600011 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0178495 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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