Basic Information
| Provider Information | |||||||||
| NPI: | 1053852855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEEB | ||||||||
| FirstName: | MYCHAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2775 STATE ROUTE 39 | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448759466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197473322 | ||||||||
| FaxNumber: | 4197473504 | ||||||||
| Practice Location | |||||||||
| Address1: | 2775 STATE ROUTE 39 | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448759466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197473322 | ||||||||
| FaxNumber: | 4197473504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2017 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1303243 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.