Provider Demographics
NPI:1568860989
Name:FACEMIRE, MATTHEW (EDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FACEMIRE
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3797 PLEASANT CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43056-9627
Mailing Address - Country:US
Mailing Address - Phone:740-763-4412
Mailing Address - Fax:
Practice Address - Street 1:3797 PLEASANT CHAPEL RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43056-9627
Practice Address - Country:US
Practice Address - Phone:740-763-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1370398103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool