Basic Information
| Provider Information | |||||||||
| NPI: | 1568868156 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAIMOND | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC-S, CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1865 N RIDGE RD E STE D | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440553359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407235482 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1865 N RIDGE RD E STE D | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440553359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407235482 | ||||||||
| FaxNumber: | 4402770459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2014 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.163919 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | E.1700459-SUPV. | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0253204 | 05 | OH | MEDICAID |