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1669132395 NPI number — ELEMENTAL LIBERATION

NPI Number: 1669132395
Health Care Provider/Practitioner: ELEMENTAL LIBERATION

Information about “1669132395” NPI (ELEMENTAL LIBERATION) exists in 1669132395 in HTML format HTML  |  1669132395 in plain Text format TXT  |  1669132395 in PDF (Portable Document Format) PDF  |  1669132395 in an XML format XML  formats.

NPI Number : 1669132395 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1669132395",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "ELEMENTAL LIBERATION",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "2703 SOL WILSON AVE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "AUSTIN",
    "MailingAddressStateName": "TX",
    "MailingAddressPostalCode": "78702-2556",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "512-650-8179",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "2703 SOL WILSON AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "AUSTIN",
    "PracticeLocationAddressStateName": "TX",
    "PracticeLocationAddressPostalCode": "78702-2556",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "512-650-8179",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "12/21/2021",
    "LastUpdateDate": "12/21/2021",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "ROSAGE",
    "AuthorizedOfficialFirstName": "VANESSA",
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": "OWNER",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "LCPC",
    "AuthorizedOfficialTelephoneNumber": "512-650-8179",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "261QM0801X",
        "TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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