Basic Information
| Provider Information | |||||||||
| NPI: | 1841798097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGEL | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | CHERI | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICDC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YATES | ||||||||
| OtherFirstName: | MISTY | ||||||||
| OtherMiddleName: | CHERI | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NONE | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 202 E BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440172058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145122310 | ||||||||
| FaxNumber: | 6149289092 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 E BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440172058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145122310 | ||||||||
| FaxNumber: | 6149289092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2018 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LICDC.162043 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.