Basic Information
| Provider Information | |||||||||
| NPI: | 1700921186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATABE | ||||||||
| FirstName: | JOLEENE | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TOWER | ||||||||
| OtherFirstName: | JOLEENE | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6183 ENKE CT | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430179517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138504824 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 715 S PLUM ST | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430401631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376449192 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | OH | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | C.0700189 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.