Basic Information
Provider Information | |||||||||
NPI: | 1275924391 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTERN RESERVE COUNSELING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 32831 REDWOOD BLVD | ||||||||
Address2: |   | ||||||||
City: | AVON LAKE | ||||||||
State: | OH | ||||||||
PostalCode: | 440121518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304612183 | ||||||||
FaxNumber: | 4409302085 | ||||||||
Practice Location | |||||||||
Address1: | 223 MILLER RD | ||||||||
Address2: |   | ||||||||
City: | AVON LAKE | ||||||||
State: | OH | ||||||||
PostalCode: | 440121004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4408228248 | ||||||||
FaxNumber: | 4409302085 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2015 | ||||||||
LastUpdateDate: | 02/11/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALE | ||||||||
AuthorizedOfficialFirstName: | ROBIN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
AuthorizedOfficialTelephone: | 4408222248 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPCC, LICDC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | E.0050965SUPV | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.