1871691667 NPI number — MICHAEL J. MERVILDE,MSW

Table of content: (NPI 1871691667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871691667 NPI number — MICHAEL J. MERVILDE,MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL J. MERVILDE,MSW
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1871691667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 S JEFFERSON ST
Provider Second Line Business Mailing Address:
SUITE 306
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54301-4500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-437-7878
Provider Business Mailing Address Fax Number:
920-437-5884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 S JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54301-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-437-7878
Provider Business Practice Location Address Fax Number:
920-437-5884
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MERVILDE
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
920-437-7878

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  107-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42158800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com