Basic Information
Provider Information | |||||||||
NPI: | 1952530560 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOUDERS | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | ANNE TYRELL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TYRELL | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 150 NEW PROVIDENCE RD | ||||||||
Address2: |   | ||||||||
City: | MOUNTAINSIDE | ||||||||
State: | NJ | ||||||||
PostalCode: | 070922590 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8882445373 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3575 QUAKERBRIDGE RD | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 086191271 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8882445373 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2009 | ||||||||
LastUpdateDate: | 01/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | 010917 | OH | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 2080P0006X | 25MB09954500 | NJ | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
No ID Information.