1053667089 NPI number — MRS. MADELEINE PETHAN M.A., CCC-SLP

Table of content: MRS. MADELEINE PETHAN M.A., CCC-SLP (NPI 1053667089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053667089 NPI number — MRS. MADELEINE PETHAN M.A., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETHAN
Provider First Name:
MADELEINE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAUGH
Provider Other First Name:
MADELEINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A., CCC-SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053667089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6035 FAIRVIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28210-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-295-3000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6035 FAIRVIEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-3256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-295-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2012

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:  PCET001789 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 12104 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1053667089 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1260932 . This is a "WELLCARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SAN138 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19KQ3 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4808956 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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