Provider Demographics
NPI:1043665946
Name:TRAIL, KAREN RONNETTA (LSW)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:RONNETTA
Last Name:TRAIL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528
Mailing Address - Country:US
Mailing Address - Phone:419-491-8828
Mailing Address - Fax:419-868-1989
Practice Address - Street 1:6715 DORR ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615
Practice Address - Country:US
Practice Address - Phone:419-868-1178
Practice Address - Fax:419-868-1989
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251S0007X, 171M00000X
OHS 0028531104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0295285Medicaid