1932746989 NPI number — ELIZABETH NUSSBAUM-GONZALEZ LSW

Table of content: ELIZABETH NUSSBAUM-GONZALEZ LSW (NPI 1932746989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932746989 NPI number — ELIZABETH NUSSBAUM-GONZALEZ LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUSSBAUM-GONZALEZ
Provider First Name:
ELIZABETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NUSSBAUM
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932746989
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 809
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOSHEN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46527-0809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-533-1234
Provider Business Mailing Address Fax Number:
574-537-2652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 LAKEVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOSHEN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46528-7000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-533-1234
Provider Business Practice Location Address Fax Number:
574-537-2652
Provider Enumeration Date:
12/09/2019

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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