Basic Information
Provider Information | |||||||||
NPI: | 1053723254 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NOVOTNY | ||||||||
FirstName: | ELISABETH | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KISPERT | ||||||||
OtherFirstName: | ELISABETH | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 445 CYPRESS ST STE 8 | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | NH | ||||||||
PostalCode: | 031033600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036684079 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 445 CYPRESS ST STE 8 | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | NH | ||||||||
PostalCode: | 031033600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036684079 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2014 | ||||||||
LastUpdateDate: | 09/12/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 18815 | NH | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.