1598807810 NPI number — MARIE T. CLAVECILLA-CHAN M.A.

Table of content: MARIE T. CLAVECILLA-CHAN M.A. (NPI 1598807810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598807810 NPI number — MARIE T. CLAVECILLA-CHAN M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLAVECILLA-CHAN
Provider First Name:
MARIE
Provider Middle Name:
T.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CUSTODIO
Provider Other First Name:
MARIE
Provider Other Middle Name:
T.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598807810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MARKET SQ
Provider Second Line Business Mailing Address:
SUITE # 10
Provider Business Mailing Address City Name:
NEWINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06111-2921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-665-1025
Provider Business Mailing Address Fax Number:
860-667-6008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MARKET SQ
Provider Second Line Business Practice Location Address:
SUITE # 10
Provider Business Practice Location Address City Name:
NEWINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06111-2921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-665-1025
Provider Business Practice Location Address Fax Number:
860-667-6008
Provider Enumeration Date:
02/13/2007

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:  001481 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 240001481CT01 . This is a "ANTHEM BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004257912 . This is a "CT MEDICAL ASSITANCE PROG" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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