1710197843 NPI number — MR. ELMER GEORGE MYRON LBSW, LISAC

Table of content: MR. ELMER GEORGE MYRON LBSW, LISAC (NPI 1710197843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710197843 NPI number — MR. ELMER GEORGE MYRON LBSW, LISAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYRON
Provider First Name:
ELMER
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LBSW, LISAC
Provider Gender Code:
M

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:
1710197843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4011 W COLUMBINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85029-2970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-481-6717
Provider Business Mailing Address Fax Number:
602-279-5393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4041 N. CENTRAL AVE
Provider Second Line Business Practice Location Address:
BUILDING C
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85012-3133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-279-5262
Provider Business Practice Location Address Fax Number:
602-279-5393
Provider Enumeration Date:
05/24/2007

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: 101YA0400X , with the licence number:  11597 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X , with the licence number: 4125 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 910209 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com