Provider Demographics
NPI:1306186648
Name:MAYLE, MARY ANNE (LISWS)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:MAYLE
Suffix:
Gender:F
Credentials:LISWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3583
Mailing Address - Country:US
Mailing Address - Phone:419-999-2010
Mailing Address - Fax:419-999-6284
Practice Address - Street 1:250 MANOR DR
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-3118
Practice Address - Country:US
Practice Address - Phone:419-874-0306
Practice Address - Fax:419-874-9295
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-24
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1201489-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0403719Medicaid