Basic Information
| Provider Information | |||||||||
| NPI: | 1508288804 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SYNERGY FAMILY THERAPY SPECIALISTS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 THOMAS PAINE PKWY | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454592541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374286273 | ||||||||
| FaxNumber: | 9374286274 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 THOMAS PAINE PKWY | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454592541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374286273 | ||||||||
| FaxNumber: | 9374286274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2014 | ||||||||
| LastUpdateDate: | 01/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | COLCLASURE | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9374286273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 07556 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QP2000X | 012405 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.