Basic Information
Provider Information | |||||||||
NPI: | 1295158079 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZOELLER | ||||||||
FirstName: | CAITLYN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HICKS | ||||||||
OtherFirstName: | CAITLYN | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1100 SHAWNEE RD | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458053583 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4199992010 | ||||||||
FaxNumber: | 4199996284 | ||||||||
Practice Location | |||||||||
Address1: | 1021 W POE RD | ||||||||
Address2: |   | ||||||||
City: | BOWLING GREEN | ||||||||
State: | OH | ||||||||
PostalCode: | 434029362 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193524694 | ||||||||
FaxNumber: | 4193531807 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2014 | ||||||||
LastUpdateDate: | 06/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.1300419-TRNE | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 0290599 | 05 | OH |   | MEDICAID |