Basic Information
| Provider Information | |||||||||
| NPI: | 1104991744 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUMBOLDT STATE UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STUDENT HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HARPST ST | ||||||||
| Address2: | BUILDING 42 | ||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955218222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078265019 | ||||||||
| FaxNumber: | 7078265042 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HARPST ST | ||||||||
| Address2: | BUILDING 42 | ||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955218222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078265019 | ||||||||
| FaxNumber: | 7078265042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 08/15/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANCOTT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7078265019 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
No ID Information.