Basic Information
| Provider Information | |||||||||
| NPI: | 1639341589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAUMEE VALLEY GUIDANCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 BIEDE AVE | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435122408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197828856 | ||||||||
| FaxNumber: | 4197822261 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 BIEDE AVE | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435122408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197828856 | ||||||||
| FaxNumber: | 4197822261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | BAILEY | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4197828856 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP0016X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
ID Information
| ID | Type | State | Issuer | Description | 0304807 | 05 | OH | MEDICAID |