1467402198 NPI number — PROFESSIONAL PSYCHOLOGICAL SERVICES LLC

Table of content: (NPI 1467402198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467402198 NPI number — PROFESSIONAL PSYCHOLOGICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PSYCHOLOGICAL SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467402198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5577 AIRPORT HWY
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43615-7378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-866-1212
Provider Business Mailing Address Fax Number:
419-866-4023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5577 AIRPORT HWY
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43615-7378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-866-1212
Provider Business Practice Location Address Fax Number:
419-866-4023
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KUNA
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DIRECTOR/OWNER
Authorized Official Telephone Number:
419-866-1212

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000503794 . This is a "ANTHEM BC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2005332 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE8465 . This is a "RR MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 291263 . This is a "MHN GROUP NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 44509020 . This is a "AETNA GROUP NUMBER" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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