Basic Information
| Provider Information | |||||||||
| NPI: | 1902428857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COUNTRYMAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC, CDCA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COUNTRYMAN | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1206 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432221319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003218283 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1207 W STATE ST STE M | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446014686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308218407 | ||||||||
| FaxNumber: | 3308218506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2020 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | C2002439TRNE | OH | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | C.2103470 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.