Basic Information
| Provider Information | |||||||||
| NPI: | 1073870846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PERSONAL & FAMILY COUNSELING SERVICES OF TUSCARAWAS VALLEY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HARBOR HOUSE, A DIVISION OF PERSONAL & FAMILY COUNSELING SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1433 5TH ST NW | ||||||||
| Address2: | |||||||||
| City: | NEW PHILADELPHIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446631223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303438171 | ||||||||
| FaxNumber: | 3303438439 | ||||||||
| Practice Location | |||||||||
| Address1: | 1433 5TH ST NW | ||||||||
| Address2: | |||||||||
| City: | NEW PHILADELPHIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446631223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303438171 | ||||||||
| FaxNumber: | 3303438439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2012 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENRY | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3303438171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS, MSSA, LISW, ACSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2863601 | 05 | OH | MEDICAID |