1629320072 NPI number — FURMA SHAUNTEL BEGLEY ALLEN LCSW

Table of content: FURMA SHAUNTEL BEGLEY ALLEN LCSW (NPI 1629320072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629320072 NPI number — FURMA SHAUNTEL BEGLEY ALLEN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
FURMA
Provider Middle Name:
SHAUNTEL BEGLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEGLEY
Provider Other First Name:
FURMA
Provider Other Middle Name:
SHAUNTEL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629320072
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4210 COLUMBIA RD
Provider Second Line Business Mailing Address:
STE 13C
Provider Business Mailing Address City Name:
MARTINEZ
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30907-0445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-833-9378
Provider Business Mailing Address Fax Number:
706-522-9104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4210 COLUMBIA RD
Provider Second Line Business Practice Location Address:
STE 13C
Provider Business Practice Location Address City Name:
MARTINEZ
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30907-0445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-833-9378
Provider Business Practice Location Address Fax Number:
706-522-9104
Provider Enumeration Date:
10/10/2012

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: 104100000X , with the licence number:  MSW004665 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003164181A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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