1750666830 NPI number — CHRISTINE L TYRRELL-BAKER PSYSHOLOGIST

Table of content: CHRISTINE L TYRRELL-BAKER PSYSHOLOGIST (NPI 1750666830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750666830 NPI number — CHRISTINE L TYRRELL-BAKER PSYSHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TYRRELL-BAKER
Provider First Name:
CHRISTINE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYSHOLOGIST
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:
1750666830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 HERALD PLACE
Provider Second Line Business Mailing Address:
4TH FLOOR
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13202-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-472-7363
Provider Business Mailing Address Fax Number:
315-701-2368

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 HERALD PLACE
Provider Second Line Business Practice Location Address:
4TH FLOOR
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13202-5002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-472-7363
Provider Business Practice Location Address Fax Number:
315-701-2368
Provider Enumeration Date:
10/20/2011

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: 103T00000X , with the licence number:  014483 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1235184235 . This is a "GRP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: BA1047 . This is a "GRP MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02994838 . This is a "GRP MEDICAID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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