1811641335 NPI number — MRS. SHELBY SOUMAR MSBP - BCBA

Table of content: MRS. SHELBY SOUMAR MSBP - BCBA (NPI 1811641335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811641335 NPI number — MRS. SHELBY SOUMAR MSBP - BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUMAR
Provider First Name:
SHELBY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSBP - BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUTTON
Provider Other First Name:
SHELBY
Provider Other Middle Name:
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:
1811641335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 ELM CREEK DR APT 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60126-5288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-701-5696
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 SLAWIN CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT PROSPECT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60056-2183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-584-7789
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2022

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: 103K00000X , with the licence number:  1-21-57189 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com