Basic Information
| Provider Information | |||||||||
| NPI: | 1174856504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAFER | ||||||||
| FirstName: | DENA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOFF | ||||||||
| OtherFirstName: | DENA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1710 KIOWA CT | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435123342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194383319 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 219 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | NAPOLEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435451698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195920540 | ||||||||
| FaxNumber: | 4195924514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.2102899 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | S 0800498 | OH | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.