Basic Information
| Provider Information | |||||||||
| NPI: | 1912424789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRALEY | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | LOU | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 N 3RD ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430555550 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 NORTH 3RD STREET | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403497511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 08/23/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.