Provider Demographics
NPI:1063479590
Name:WESTERN RESERVE PSYCHOLOGICAL ASSOC INC
Entity Type:Organization
Organization Name:WESTERN RESERVE PSYCHOLOGICAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:FOWKES
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:330-650-6338
Mailing Address - Street 1:4833 DARROW ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1411
Mailing Address - Country:US
Mailing Address - Phone:330-650-5338
Mailing Address - Fax:330-342-3837
Practice Address - Street 1:4833 DARROW ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1411
Practice Address - Country:US
Practice Address - Phone:330-650-5338
Practice Address - Fax:330-342-3837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9248282Medicare PIN
9248283Medicare ID - Type Unspecified