1871520304 NPI number — SUE ELLEN GOSTANIAN LPC

Table of content: SUE ELLEN GOSTANIAN LPC (NPI 1871520304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871520304 NPI number — SUE ELLEN GOSTANIAN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOSTANIAN
Provider First Name:
SUE
Provider Middle Name:
ELLEN
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:
1871520304
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:
2 OLD NEW MILFORD RD
Provider Second Line Business Mailing Address:
2F
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06804-2426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-775-2583
Provider Business Mailing Address Fax Number:
203-775-2863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 OLD NEW MILFORD RD
Provider Second Line Business Practice Location Address:
2F
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06804-2426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-775-2583
Provider Business Practice Location Address Fax Number:
203-775-2863
Provider Enumeration Date:
06/28/2006

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: 101YP2500X , with the licence number:  000111 , 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)

  • Identifier: 0004332774 . This is a "AETNA HEALTH CARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1065880000 . This is a "MAGELLAN HEALTH CARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P1093372 . This is a "OXFORD HEALTH CARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 018638 . This is a "MHN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 240000111CT01 . This is a "ABH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9374982 . This is a "PHCS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0102904 . This is a "GHI" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 132249 . This is a "VALUE OPTIONS" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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