1699802074 NPI number — VIVIAN JEAN DEETJEN BA

Table of content: VIVIAN JEAN DEETJEN BA (NPI 1699802074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699802074 NPI number — VIVIAN JEAN DEETJEN BA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEETJEN
Provider First Name:
VIVIAN
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BA
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:
1699802074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3579 KNERR DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACUNGIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-454-5741
Provider Business Mailing Address Fax Number:
908-213-0644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
492 ROUTE 57 WEST
Provider Second Line Business Practice Location Address:
FAMILY GUIDANCE CENTER OF WARREN COUNTY
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-689-1000
Provider Business Practice Location Address Fax Number:
908-589-4529
Provider Enumeration Date:
02/27/2007

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: 101YM0800X , with the licence number:  S-4121 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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