1073103628 NPI number — CAROLINE MARETHA RAY MA, LPC, NCC, ACS

Table of content: CAROLINE MARETHA RAY MA, LPC, NCC, ACS (NPI 1073103628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073103628 NPI number — CAROLINE MARETHA RAY MA, LPC, NCC, ACS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAY
Provider First Name:
CAROLINE
Provider Middle Name:
MARETHA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, NCC, ACS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMAS
Provider Other First Name:
CAROLINE
Provider Other Middle Name:
MARETHA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073103628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 S LAUDERDALE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49006-4348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-352-6713
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5340 HOLIDAY TER STE 13
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49009-2181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-372-4140
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2021

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:  6401018585 , 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)





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