1801438981 NPI number — JOHN-TYLER MARKETTE COUNSELING

Table of content: JOHN-TYLER MARKETTE COUNSELING (NPI 1801438981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801438981 NPI number — JOHN-TYLER MARKETTE COUNSELING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARKETTE
Provider First Name:
JOHN-TYLER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COUNSELING
Provider Gender Code:
M

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:
1801438981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 COLUMBUS AVENUE
Provider Second Line Business Mailing Address:
CREDENTIALING SPECIALIST
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-503-3000
Provider Business Mailing Address Fax Number:
203-503-3183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 GRANT STREET
Provider Second Line Business Practice Location Address:
GRANT STREET PARTNERSHIP
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06519-3456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-503-3350
Provider Business Practice Location Address Fax Number:
203-503-3370
Provider Enumeration Date:
10/10/2019

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: 101YP2500X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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