1679606677 NPI number — GWEN PATRIARCA SLP

Table of content: GWEN PATRIARCA SLP (NPI 1679606677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679606677 NPI number — GWEN PATRIARCA SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATRIARCA
Provider First Name:
GWEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
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:
1679606677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88102-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-769-4490
Provider Business Mailing Address Fax Number:
575-769-4533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 SUTTER PLACE
Provider Second Line Business Practice Location Address:
STUDENT SUPPORT CENTER
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88012-9000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-769-4490
Provider Business Practice Location Address Fax Number:
575-769-4533
Provider Enumeration Date:
03/13/2007

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: 235Z00000X , with the licence number:  655 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X , with the licence number: 655 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K 3216 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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