1790859262 NPI number — MRS. MICHELE M BRANNAN LICENSED CLINICAL ME

Table of content: MRS. MICHELE M BRANNAN LICENSED CLINICAL ME (NPI 1790859262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790859262 NPI number — MRS. MICHELE M BRANNAN LICENSED CLINICAL ME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANNAN
Provider First Name:
MICHELE
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED CLINICAL ME
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:
1790859262
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 401
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-472-8657
Provider Business Mailing Address Fax Number:
603-672-4546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 RTE 101
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-472-8657
Provider Business Practice Location Address Fax Number:
603-672-4546
Provider Enumeration Date:
11/17/2006

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

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

  • Identifier: 29370 . This is a "NATIONAL BOARD OF CERTIFI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 80009139 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24 . This is a "BOARD OF PSYCHOLOGY & MEN" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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