1679648638 NPI number — MS. REBECCA HARDY L.C.S.W.

Table of content: MS. REBECCA HARDY L.C.S.W. (NPI 1679648638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679648638 NPI number — MS. REBECCA HARDY L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARDY
Provider First Name:
REBECCA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
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:
1679648638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 4841
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83205-4841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-904-1573
Provider Business Mailing Address Fax Number:
208-904-1583

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1257 EAST CENTER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-1257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-904-1583
Provider Business Practice Location Address Fax Number:
208-904-1583
Provider Enumeration Date:
11/22/2006

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: 101YA0400X , with the licence number:  40 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 666 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 32114 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 005062 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5722229 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1036664 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010826 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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