Provider Demographics
NPI:1366011132
Name:DEMOSS, MAKAYLA ROSE
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:ROSE
Last Name:DEMOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4737
Mailing Address - Country:US
Mailing Address - Phone:419-557-5177
Mailing Address - Fax:
Practice Address - Street 1:76 ASHWOOD DR
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-1908
Practice Address - Country:US
Practice Address - Phone:419-448-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2204435-TRNE390200000X
OHC.2305676101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator