1740295617 NPI number — PAIGE A LEAVITT-HALSALL

Table of content: PAIGE A LEAVITT-HALSALL (NPI 1740295617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740295617 NPI number — PAIGE A LEAVITT-HALSALL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAVITT-HALSALL
Provider First Name:
PAIGE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1740295617
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 CHARLES ELDRIDGE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEVILLE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-947-1683
Provider Business Mailing Address Fax Number:
508-947-1684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 CHARLES ELDRIDGE DRIVE
Provider Second Line Business Practice Location Address:
TRANQUIL MIND & WELLNESS INC
Provider Business Practice Location Address City Name:
LAKEVILLE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-947-1683
Provider Business Practice Location Address Fax Number:
508-947-1684
Provider Enumeration Date:
07/29/2006

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: 163WP0808X , with the licence number:  APRN175441 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364S00000X , with the licence number: APRN175441 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 271408 . This is a "BLUE CROSS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 2173937 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33106235303 . This is a "PACIFICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 469386 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1895028 . This is a "MBHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: PN0805 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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