1558806919 NPI number — MR. ALFONSO ALCANCIA LCSW CANDIDATE

Table of content: MR. ALFONSO ALCANCIA LCSW CANDIDATE (NPI 1558806919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558806919 NPI number — MR. ALFONSO ALCANCIA LCSW CANDIDATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALCANCIA
Provider First Name:
ALFONSO
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW CANDIDATE
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALCANCIA
Provider Other First Name:
ALFONSO
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW CANDIDATE
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1558806919
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9502 S I-35 SERVICE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-334-9430
Provider Business Mailing Address Fax Number:
405-767-6285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7301 BROADWAY EXT
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73116-9045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-767-1126
Provider Business Practice Location Address Fax Number:
405-767-6285
Provider Enumeration Date:
12/21/2016

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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