1831625664 NPI number — FANCI RAE PULLIAM LCPC

Table of content: FANCI RAE PULLIAM LCPC (NPI 1831625664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831625664 NPI number — FANCI RAE PULLIAM LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PULLIAM
Provider First Name:
FANCI
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LYMAN
Provider Other First Name:
FANCI
Provider Other Middle Name:
RAE
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:
1831625664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3089
Provider Second Line Business Mailing Address:
CENTER FOR MENTAL HEALTH
Provider Business Mailing Address City Name:
GREAT FALLS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59403-3089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-761-2100
Provider Business Mailing Address Fax Number:
406-791-9629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 19TH AVE S
Provider Second Line Business Practice Location Address:
CENTER FOR MENTAL HEALTH/SUNNYSIDE
Provider Business Practice Location Address City Name:
GREAT FALLS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59405-6130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-761-2100
Provider Business Practice Location Address Fax Number:
406-791-9629
Provider Enumeration Date:
05/11/2017

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:  17543 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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