1902059637 NPI number — MRS. BRENDA M VAN WIE M.A. C.C.C.-SLP

Table of content: MRS. BRENDA M VAN WIE M.A. C.C.C.-SLP (NPI 1902059637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902059637 NPI number — MRS. BRENDA M VAN WIE M.A. C.C.C.-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN WIE
Provider First Name:
BRENDA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A. C.C.C.-SLP
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:
1902059637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2142 STATE ROUTE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT EDWARD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12828-3409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-747-0843
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2142 STATE ROUTE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT EDWARD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12828-3409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-747-0843
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2008

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: 235Z00000X , with the licence number:  006161-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01060966 . This is a "AMERICAN SPEECH AND HEARING ASSOCIATION ASHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 006161-1 . This is a "NEW YORK STATE LICENSE IN SPEECH PATHOLOGY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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