1720334600 NPI number — SHELLY MARSHALL LCSE

Table of content: SHELLY MARSHALL LCSE (NPI 1720334600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720334600 NPI number — SHELLY MARSHALL LCSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARSHALL
Provider First Name:
SHELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSE
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:
1720334600
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 GREENWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02809-4209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-862-4335
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1516 ATWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTON
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02919-3223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-553-1000
Provider Business Practice Location Address Fax Number:
401-722-5280
Provider Enumeration Date:
07/30/2012

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GH57134 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com