Basic Information
| Provider Information | |||||||||
| NPI: | 1083713770 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEFIANCE REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEFIANCE REGIONAL PSYCHIATRIC SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 RALSTON AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435125311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197836805 | ||||||||
| FaxNumber: | 4197836804 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 RALSTON AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435125311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197836805 | ||||||||
| FaxNumber: | 4197836804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | PEFFLEY | ||||||||
| AuthorizedOfficialFirstName: | JEANNE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4197836805 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I0004427 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.