1750019972 NPI number — KATE INDUNI BICKHAM SSP

Table of content: KATE INDUNI BICKHAM SSP (NPI 1750019972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750019972 NPI number — KATE INDUNI BICKHAM SSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BICKHAM
Provider First Name:
KATE
Provider Middle Name:
INDUNI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SSP
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:
1750019972
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
154 PLEASANT VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES ALLEMANDS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70030-3315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-258-6271
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARRERO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70072-1943
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-349-7600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2022

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: 103TS0200X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1701033 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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