1760946891 NPI number — KELLI MARIE GACIC

Table of content: MS. BRIDGET MARY BREEN LMHC (NPI 1407352081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760946891 NPI number — KELLI MARIE GACIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GACIC
Provider First Name:
KELLI
Provider Middle Name:
MARIE
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:
ROMERO
Provider Other First Name:
KELLI
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760946891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1477 W COMMERCE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85746-6016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-792-3293
Provider Business Mailing Address Fax Number:
520-792-4336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 N ALVERNON WAY STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85711-1066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-207-9348
Provider Business Practice Location Address Fax Number:
520-345-5980
Provider Enumeration Date:
01/23/2019

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: 1041C0700X , with the licence number:  LCSW-17607 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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