Basic Information
Provider Information | |||||||||
NPI: | 1598862641 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY LIFE COUNSELING & PSYCHIATRIC SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 151 MARION AVE | ||||||||
Address2: |   | ||||||||
City: | MANSFIELD | ||||||||
State: | OH | ||||||||
PostalCode: | 449032223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197749969 | ||||||||
FaxNumber: | 4197565781 | ||||||||
Practice Location | |||||||||
Address1: | 151 MARION AVE | ||||||||
Address2: |   | ||||||||
City: | MANSFIELD | ||||||||
State: | OH | ||||||||
PostalCode: | 449032223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197749969 | ||||||||
FaxNumber: | 4197565781 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 07/16/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURGGRAF | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4197749969 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD, LPCCE, 1MFT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 10440 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 0405 | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.