Provider Demographics
NPI:1376631713
Name:SOUTHWESTERN OHIO BEHAVIORAL HEALTH,LLC
Entity Type:Organization
Organization Name:SOUTHWESTERN OHIO BEHAVIORAL HEALTH,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:SHAFFER
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:937-435-8864
Mailing Address - Street 1:PO BOX 41158
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45441-0158
Mailing Address - Country:US
Mailing Address - Phone:937-435-8864
Mailing Address - Fax:937-435-8264
Practice Address - Street 1:35 IRONGATE PARK DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4616
Practice Address - Country:US
Practice Address - Phone:937-435-8864
Practice Address - Fax:937-435-8264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4664103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSO9351261Medicare PIN