Provider Demographics
NPI:1376589812
Name:COUNSELING CENTER FOR WELLNESS LLC
Entity Type:Organization
Organization Name:COUNSELING CENTER FOR WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:R
Authorized Official - Last Name:AGNEW
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LISW-S, LCDC-II
Authorized Official - Phone:419-222-7180
Mailing Address - Street 1:222 S WEST ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4842
Mailing Address - Country:US
Mailing Address - Phone:419-222-7180
Mailing Address - Fax:419-228-8439
Practice Address - Street 1:222 S WEST ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4842
Practice Address - Country:US
Practice Address - Phone:419-222-7180
Practice Address - Fax:419-228-8439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-0002118101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCO9354661Medicare ID - Type Unspecified