Basic Information
| Provider Information | |||||||||
| NPI: | 1083215131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WARREN COUNTY ESC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1879 DEERFIELD RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450368602 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1879 DEERFIELD RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450368602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136952900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | WOODY | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | LEAD MENTAL HEALTH THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9376819164 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPCC-S | ||||||||
| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.