Basic Information
| Provider Information | |||||||||
| NPI: | 1306186648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYLE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISWS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199992010 | ||||||||
| FaxNumber: | 4199996284 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 MANOR DR | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435513118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198740306 | ||||||||
| FaxNumber: | 4198749295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2013 | ||||||||
| LastUpdateDate: | 06/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.1201489-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0403719 | 05 | OH | MEDICAID |