Basic Information
Provider Information | |||||||||
NPI: | 1932526092 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REARDEN | ||||||||
FirstName: | LARIN | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CRAWFORD-BARHAM | ||||||||
OtherFirstName: | LARIN | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 305 N 5TH ST | ||||||||
Address2: |   | ||||||||
City: | IRONTON | ||||||||
State: | OH | ||||||||
PostalCode: | 456381578 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405324858 | ||||||||
FaxNumber: | 7405324859 | ||||||||
Practice Location | |||||||||
Address1: | 10777 COUNTY ROAD 107 | ||||||||
Address2: |   | ||||||||
City: | PROCTORVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 456698130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403020541 | ||||||||
FaxNumber: | 7408860255 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2014 | ||||||||
LastUpdateDate: | 10/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S1451233 | OH | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 104100000X | 01092014 | KY | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 104100000X | I1700255 | OH | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 1932526092 | 05 | WV |   | MEDICAID | 0225208 | 05 | OH |   | MEDICAID | 7100460900 | 05 | KY |   | MEDICAID |