Basic Information
| Provider Information | |||||||||
| NPI: | 1457778862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARNISH | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 WOODLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437253094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556927247 | ||||||||
| FaxNumber: | 1855692724 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 WOODLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437253094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556927247 | ||||||||
| FaxNumber: | 1855692724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2014 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S1303581 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | 101YA0400X | 161016 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1457778862 | 05 | OH | MEDICAID |