Provider Demographics
NPI:1073031373
Name:VAIR, PHYLLIS ANN (MED, LPC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ANN
Last Name:VAIR
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3513
Mailing Address - Country:US
Mailing Address - Phone:330-807-0028
Mailing Address - Fax:
Practice Address - Street 1:135 E ERIE ST STE 302
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-3594
Practice Address - Country:US
Practice Address - Phone:330-593-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1500573101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor