1003842725 NPI number — LAUREN JANE BAL LBSW

Table of content: LAUREN JANE BAL LBSW (NPI 1003842725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003842725 NPI number — LAUREN JANE BAL LBSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAL
Provider First Name:
LAUREN
Provider Middle Name:
JANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LBSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEBERNARDI
Provider Other First Name:
LAUREN
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LBSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003842725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
715 PYLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49802-4456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-774-0522
Provider Business Mailing Address Fax Number:
906-774-1570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 PYLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49802-4456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-774-0522
Provider Business Practice Location Address Fax Number:
906-774-1570
Provider Enumeration Date:
06/24/2006

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: 104100000X , with the licence number:  6802066593 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LB066593 . This is a "BCBS OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com