Basic Information
| Provider Information | |||||||||
| NPI: | 1326294364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRERA | ||||||||
| FirstName: | CHASITY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TIETJE | ||||||||
| OtherFirstName: | CHASITY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1100 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199992010 | ||||||||
| FaxNumber: | 4199996284 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEIPSIC | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458569326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199992010 | ||||||||
| FaxNumber: | 4199996284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2008 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | I.1000325-SUPV | OH | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | S0031200 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | S.1000325-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0220584 | 05 | OH | MEDICAID |