1790886752 NPI number — MISS SUSAN A. WANGERMAN MA, LSW, LMHC

Table of content: MISS SUSAN A. WANGERMAN MA, LSW, LMHC (NPI 1790886752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790886752 NPI number — MISS SUSAN A. WANGERMAN MA, LSW, LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANGERMAN
Provider First Name:
SUSAN
Provider Middle Name:
A.
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MA, LSW, LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERSON
Provider Other First Name:
SUSAN
Provider Other Middle Name:
WANGERMAN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790886752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLEANS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02653-6366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-255-3866
Provider Business Mailing Address Fax Number:
508-255-3790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 CHASE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLEANS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02653-3103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-255-3866
Provider Business Practice Location Address Fax Number:
508-255-3790
Provider Enumeration Date:
09/25/2006

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:  4068 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 104100000X , with the licence number: 3025778 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: BC/BS OF MA . This is a "ALL PRODUCTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1895052 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 354857 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 454542 . This is a "TUFTS HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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