Basic Information
| Provider Information | |||||||||
| NPI: | 1902295405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOSTOFF | ||||||||
| FirstName: | MARCIA | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 S HAYES ST | ||||||||
| Address2: | |||||||||
| City: | BELLEFONTAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433112407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5672241878 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1522 E US HIGHWAY 36 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | URBANA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430789738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376535583 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2015 | ||||||||
| LastUpdateDate: | 04/26/2017 | ||||||||
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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 | 101YM0800X | C 1200402 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | E.1700160 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.