1598808396 NPI number — HENRIETTA S POONS LCPC

Table of content: HENRIETTA S POONS LCPC (NPI 1598808396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598808396 NPI number — HENRIETTA S POONS LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POONS
Provider First Name:
HENRIETTA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
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:
1598808396
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:
650 EVERGREEN WOODS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-942-1565
Provider Business Mailing Address Fax Number:
207-942-7430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 EVERGREEN WOODS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-942-1565
Provider Business Practice Location Address Fax Number:
207-942-7430
Provider Enumeration Date:
02/14/2007

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:  CC749 , 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)

  • Identifier: 047526 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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