1700849148 NPI number — The Changing Tide Body, Mind & Spirit P.C. Carolyn South L.P.C.

Table of content: Carolyn South L.P.C. (NPI 1700849148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700849148 NPI number — The Changing Tide Body, Mind & Spirit P.C. Carolyn South L.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
The Changing Tide Body, Mind & Spirit P.C.
Provider Last Name:
South
Provider First Name:
Carolyn
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.P.C.
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:
1700849148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 main street
Provider Second Line Business Mailing Address:
ste a
Provider Business Mailing Address City Name:
mathews
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23109-0327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804725-3041
Provider Business Mailing Address Fax Number:
804-725-3510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 Main Street
Provider Second Line Business Practice Location Address:
Ste A
Provider Business Practice Location Address City Name:
mathews
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23109-0327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-725-3041
Provider Business Practice Location Address Fax Number:
8047253510
Provider Enumeration Date:
04/07/2006

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: 101YP2500X , with the licence number:  0701001882 , registered in the state of Virginia ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: 0717000854 , registered in the state of Virginia ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 250214 . This is a "HEALTHKEEPERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 250214 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 250214 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 324680 . This is a "TRICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: O85674 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7274243 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: O85674 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 409486 . This is a "VALUE OPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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