Basic Information
| Provider Information | |||||||||
| NPI: | 1801000120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNSELING AND NEUROTHERAPY ASSOCIATES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DARBY CREEK COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1375 US HIGHWAY 42 SE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LONDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431409548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408458652 | ||||||||
| FaxNumber: | 6145030899 | ||||||||
| Practice Location | |||||||||
| Address1: | 1375 US HIGHWAY 42 SE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LONDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431409548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408458652 | ||||||||
| FaxNumber: | 6145030899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | MAUST | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | STATUTORY AGENT | ||||||||
| AuthorizedOfficialTelephone: | 7408458652 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MED LPCC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 001273 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | E-0002792 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | S.0022849 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 101YP2500X | C1400288 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | E1444 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0181670 | 05 | OH | MEDICAID |