Basic Information
| Provider Information | |||||||||
| NPI: | 1932539772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY LIFE COUNSELING & PSYCIATRIC SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032223 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 S CLAY ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MILLERSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446541329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197749969 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2013 | ||||||||
| LastUpdateDate: | 11/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | BURGGRAF | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4197749969 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD, LPCCE, 1MFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0405 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.