Basic Information
| Provider Information | |||||||||
| NPI: | 1114431244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAMBERT | ||||||||
| FirstName: | CARLEY | ||||||||
| MiddleName: | SUZANNE | ||||||||
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| Credential: | QMHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197749969 | ||||||||
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| Practice Location | |||||||||
| Address1: | 117 BLOSSOM CENTRE BLVD | ||||||||
| Address2: | |||||||||
| City: | WILLARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448909317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5675603586 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2017 | ||||||||
| LastUpdateDate: | 11/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 341869667 | 05 | OH | MEDICAID |