1811123912 NPI number — MICHELLE STALLWORTH LPC

Table of content: MICHELLE STALLWORTH LPC (NPI 1811123912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811123912 NPI number — MICHELLE STALLWORTH LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STALLWORTH
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1811123912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 LORENZ INDUSTRIAL PARKWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEDYARD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06339-1946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-464-3045
Provider Business Mailing Address Fax Number:
860-464-3044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 MONTAUK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW LONDON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06320-4700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-444-5125
Provider Business Practice Location Address Fax Number:
860-444-4767
Provider Enumeration Date:
06/03/2009

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 , with the licence number:  000432 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1811123912 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com