1588729149 NPI number — MS. LESTARI WISNU MEIER MA NCC LPC

Table of content: MS. LESTARI WISNU MEIER MA NCC LPC (NPI 1588729149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588729149 NPI number — MS. LESTARI WISNU MEIER MA NCC LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEIER
Provider First Name:
LESTARI
Provider Middle Name:
WISNU
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA NCC LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PURBASARI
Provider Other First Name:
LESTARI
Provider Other Middle Name:
WISNU
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1588729149
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:
7150 N TERRA VISTA DR
Provider Second Line Business Mailing Address:
APT #502
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-1350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-692-6912
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3020 W WILLOW KNOLLS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-681-5850
Provider Business Practice Location Address Fax Number:
309-681-5658
Provider Enumeration Date:
12/26/2006

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:  178.04217 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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