1699052555 NPI number — STACI GOTTLIEB RN, MSN, PMHNP

Table of content: STACI GOTTLIEB RN, MSN, PMHNP (NPI 1699052555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699052555 NPI number — STACI GOTTLIEB RN, MSN, PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOTTLIEB
Provider First Name:
STACI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, MSN, PMHNP
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:
1699052555
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 99371
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76199-0371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-885-1855
Provider Business Mailing Address Fax Number:
682-885-7347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 7TH AVE
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-2722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-885-1050
Provider Business Practice Location Address Fax Number:
682-885-7572
Provider Enumeration Date:
11/07/2011

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: 363LP0808X , with the licence number:  741675 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 293955505 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 293955504 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8600NA . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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