Provider Demographics
NPI:1083667828
Name:DAKOTA PROFESSIONAL CORP
Entity Type:Organization
Organization Name:DAKOTA PROFESSIONAL CORP
Other - Org Name:PROFESSIONAL PSYCHOLOGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO OF PROFESSIONAL PSYCH ASSOC
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAHLSING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:419-999-2024
Mailing Address - Street 1:3611 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804
Mailing Address - Country:US
Mailing Address - Phone:419-999-2024
Mailing Address - Fax:419-999-2024
Practice Address - Street 1:3745 SHAWNEE RD STE 105
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45806-1662
Practice Address - Country:US
Practice Address - Phone:419-999-2024
Practice Address - Fax:419-999-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5830103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH47586656100OtherBWC RISK #1313922
C01974Medicare UPIN
OHFACP25592Medicare ID - Type Unspecified
OHDA9331921Medicare ID - Type Unspecified