Basic Information
Provider Information | |||||||||
NPI: | 1891058350 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONWAY | ||||||||
FirstName: | RHONDA | ||||||||
MiddleName: | SUSANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BAXTER | ||||||||
OtherFirstName: | RHONDA | ||||||||
OtherMiddleName: | SUSANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSW, LSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 15717 SPERRY RD | ||||||||
Address2: |   | ||||||||
City: | VERMILION | ||||||||
State: | OH | ||||||||
PostalCode: | 440899268 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4403873368 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6140 S BROADWAY | ||||||||
Address2: |   | ||||||||
City: | LORAIN | ||||||||
State: | OH | ||||||||
PostalCode: | 440533821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4402337232 | ||||||||
FaxNumber: | 4402339070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2012 | ||||||||
LastUpdateDate: | 04/11/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I1201076SUPV | OH | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.