Basic Information
| Provider Information | |||||||||
| NPI: | 1639121668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYER | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 CLEVELAND AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447021805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304538252 | ||||||||
| FaxNumber: | 3304536716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 W MAIN ST STE A | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446411114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308755544 | ||||||||
| FaxNumber: | 3308758150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.0030945 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 1.0030945-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0183464 | 05 | OH | MEDICAID |