Basic Information
| Provider Information | |||||||||
| NPI: | 1679079651 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TANYA M. PURCELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3816 SCHNEIDER RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436143652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193046895 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1627 HENTHORNE DR STE D | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435371370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193046895 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2018 | ||||||||
| LastUpdateDate: | 03/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | PURCELL | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4193046895 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LPCC-S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 1100246SUPV | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.