1821135195 NPI number — MS. JEAN ELICK MACH LPC, ATR

Table of content: MS. JEAN ELICK MACH LPC, ATR (NPI 1821135195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821135195 NPI number — MS. JEAN ELICK MACH LPC, ATR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACH
Provider First Name:
JEAN
Provider Middle Name:
ELICK
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, ATR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LONG
Provider Other First Name:
JEAN
Provider Other Middle Name:
ELICK
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:
1821135195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 W. DAVIS STREET
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-401-9701
Provider Business Mailing Address Fax Number:
832-565-1010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 W. DAVIS STREET
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-401-9701
Provider Business Practice Location Address Fax Number:
832-565-1010
Provider Enumeration Date:
01/30/2007

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: 221700000X , with the licence number:  97-040 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: 14157 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1810749-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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