Basic Information
| Provider Information | |||||||||
| NPI: | 1477746451 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY SERVICES OF NORTHWEST OHIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7320 STATE HIGHWAY 108 STE A | ||||||||
| Address2: | |||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435678201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193353732 | ||||||||
| FaxNumber: | 4193353462 | ||||||||
| Practice Location | |||||||||
| Address1: | 7320 STATE HIGHWAY 108 STE A | ||||||||
| Address2: | |||||||||
| City: | WAUSEON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435678201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193353732 | ||||||||
| FaxNumber: | 4193353462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAFFER | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 4193353732 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | C.0500030 | OH | Y | Agencies | Community/Behavioral Health |
No ID Information.