Provider Demographics
NPI:1578913356
Name:WESTERN OHIO PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:WESTERN OHIO PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYD
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-638-5210
Mailing Address - Street 1:110 E POPLAR ST
Mailing Address - Street 2:STE. 7
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-2985
Mailing Address - Country:US
Mailing Address - Phone:937-638-5210
Mailing Address - Fax:
Practice Address - Street 1:110 E POPLAR ST
Practice Address - Street 2:STE. 7
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-2985
Practice Address - Country:US
Practice Address - Phone:937-638-5210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7027103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH61000064Medicaid