1790818243 NPI number — MS. LISA DREY CNS

Table of content: MS. LISA DREY CNS (NPI 1790818243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790818243 NPI number — MS. LISA DREY CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DREY
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CNS
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:
1790818243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1065 NE 125TH ST
Provider Second Line Business Mailing Address:
SUITE 409
Provider Business Mailing Address City Name:
NORTH MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33161-5821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-852-6672
Provider Business Mailing Address Fax Number:
305-891-4228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8671 S QUEBEC ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
HIGHLANDS RANCH
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80130-5859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-852-6672
Provider Business Practice Location Address Fax Number:
305-891-4228
Provider Enumeration Date:
03/13/2007

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: 363L00000X , with the licence number:  72783 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364S00000X , with the licence number: 72783 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 26627311 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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