Provider Demographics
NPI:1235486283
Name:BACON, BARBARA M (LISW-S)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:M
Last Name:BACON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3591 RESERVE COMMONS DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-5334
Mailing Address - Country:US
Mailing Address - Phone:330-764-7916
Mailing Address - Fax:330-723-6399
Practice Address - Street 1:3591 RESERVE COMMONS DR
Practice Address - Street 2:SUITE 301
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5334
Practice Address - Country:US
Practice Address - Phone:330-764-7916
Practice Address - Fax:330-723-6399
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0007356-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical