1659412997 NPI number — BRIDGING THE GAP WITH LIFE SKILLS

Table of content: ANNA MARIE O'HARE OTA (NPI 1720424252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659412997 NPI number — BRIDGING THE GAP WITH LIFE SKILLS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGING THE GAP WITH LIFE SKILLS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1659412997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 N PERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27601-1047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-833-2544
Provider Business Mailing Address Fax Number:
919-833-0939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2507 BLACKWOLF RUN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27604-5425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-250-9546
Provider Business Practice Location Address Fax Number:
919-250-7569
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WORTHINGTON
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
Authorized Official Title or Position:
QUALITY SERVIES DIRECTOR
Authorized Official Telephone Number:
919-833-2544

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  MHL092571 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6604129 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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