Basic Information
| Provider Information | |||||||||
| NPI: | 1124284930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWEENEY | ||||||||
| FirstName: | ALDENA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCDCIII | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROGERS | ||||||||
| OtherFirstName: | ALDENA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 511 PERRY ST | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435122123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197829920 | ||||||||
| FaxNumber: | 4197842523 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 W SOUTH BOUNDARY ST BLDG 6 | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435515235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143390806 | ||||||||
| FaxNumber: | 4197842523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2008 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | OH | Y | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2910854 | 05 | OH | MEDICAID |