Basic Information
| Provider Information | |||||||||
| NPI: | 1124388517 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TUSCARAWAS COUNTY AUDITOR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALCOHOL AND ADDICTION PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 897 E IRON AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446222030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303435555 | ||||||||
| FaxNumber: | 3303648946 | ||||||||
| Practice Location | |||||||||
| Address1: | 897 E IRON AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446222030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303435555 | ||||||||
| FaxNumber: | 3303648946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2012 | ||||||||
| LastUpdateDate: | 05/21/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FANNING | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3303434928 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TUSCARAWAS COUNTY AUDITOR | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 1556 | OH | N | Agencies | Community/Behavioral Health | 251S00000X | 1520 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1556 | 01 | OH | OHIO DEPARTMENT OF ALCOHOL AND DRUG ADDICTION SERVICES | OTHER | 1520 | 01 | OH | OHIO DEPARTMENT OF ALCOHOL AND DRUG ADDICTION SERVICES | OTHER |