Provider Demographics
NPI: | 1518588441 |
---|---|
Name: | GLORIA M ESQUIVEL-LYNCH LLC |
Entity Type: | Organization |
Organization Name: | GLORIA M ESQUIVEL-LYNCH LLC |
Other - Org Name: | LUNA WELLNESS LLC |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER/CLINICAL SOCIAL WORKER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | GLORIA |
Authorized Official - Middle Name: | MARIE |
Authorized Official - Last Name: | ESQUIVEL-LYNCH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LISW-S |
Authorized Official - Phone: | 419-739-7002 |
Mailing Address - Street 1: | PO BOX 62 |
Mailing Address - Street 2: | |
Mailing Address - City: | WAPAKONETA |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45895-0062 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 404 HAMILTON RD STE 4 |
Practice Address - Street 2: | |
Practice Address - City: | WAPAKONETA |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45895-1156 |
Practice Address - Country: | US |
Practice Address - Phone: | 419-739-7002 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-05-01 |
Last Update Date: | 2021-05-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |