1831213784 NPI number — MARIA T DEAUGUSTINO LPC

Table of content: MARIA T DEAUGUSTINO LPC (NPI 1831213784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831213784 NPI number — MARIA T DEAUGUSTINO LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEAUGUSTINO
Provider First Name:
MARIA
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1831213784
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 STONEHOUSE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW WILMINGTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16142-1623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-674-1594
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3143 MAIN ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST MIDDLESEX
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16159-3419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-674-1594
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2007

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: 101YM0800X , with the licence number:  PC001064 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: PC001064 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110704 . This is a "VALUE OPTIONS VENDOR NUMB" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001308035 . This is a "MANAGED CARE VENDOR NUMBE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001578297 . This is a "KEYSTONE BLUE WEST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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