Basic Information
| Provider Information | |||||||||
| NPI: | 1235680901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YEAGER | ||||||||
| FirstName: | PAM | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 S BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443081529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302533100 | ||||||||
| FaxNumber: | 3302535248 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 5TH ST SE STE 6 | ||||||||
| Address2: | |||||||||
| City: | BARBERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442034257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307450081 | ||||||||
| FaxNumber: | 3307456578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2016 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN.142484-M-IV | OH | N | Nursing Service Providers | Licensed Practical Nurse | 104100000X | I.2002131-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | I.2002131-SUPR | 05 | OH | MEDICAID |