Basic Information
| Provider Information | |||||||||
| NPI: | 1245588375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FASIG | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC-S, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 246 NORTHLAND DR STE 200A | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307259195 | ||||||||
| FaxNumber: | 3307259187 | ||||||||
| Practice Location | |||||||||
| Address1: | 246 NORTHLAND DR STE 200A | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307259195 | ||||||||
| FaxNumber: | 3307259187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2012 | ||||||||
| LastUpdateDate: | 03/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LICDC.161660 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LE-00019042 | OH | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | E.1300003-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0181362 | 05 | OH | MEDICAID |