1629493473 NPI number — MS. ELIZABETH GRACE MENAKER LCSW

Table of content: MS. ELIZABETH GRACE MENAKER LCSW (NPI 1629493473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629493473 NPI number — MS. ELIZABETH GRACE MENAKER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENAKER
Provider First Name:
ELIZABETH
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MS.
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:
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:
1629493473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 W DICKERSON ST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BOZEMAN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59718-6851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-207-9763
Provider Business Mailing Address Fax Number:
406-587-2292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1940 W DICKERSON ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59718-6851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-207-9763
Provider Business Practice Location Address Fax Number:
406-587-2292
Provider Enumeration Date:
03/03/2014

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:  087906-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 12272 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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