1770776429 NPI number — MS. ELAINE THERESE CONWAY MS, LPC

Table of content: MS. ELAINE THERESE CONWAY MS, LPC (NPI 1770776429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770776429 NPI number — MS. ELAINE THERESE CONWAY MS, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONWAY
Provider First Name:
ELAINE
Provider Middle Name:
THERESE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MELLEN
Provider Other First Name:
ELAINE
Provider Other Middle Name:
CONWAY
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:
1770776429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3900 W BROWN DEER RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BROWN DEER
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53209-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-540-2170
Provider Business Mailing Address Fax Number:
414-540-2171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
934 S CLAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54301-3419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-819-6570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2007

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: 101YM0800X , with the licence number:  3537-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 40953300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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