Provider Demographics
NPI:1679469225
Name:STAWOWY, EDISON
Entity type:Individual
Prefix:
First Name:EDISON
Middle Name:
Last Name:STAWOWY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 COUNTY ROAD 119
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-9384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:326 COUNTY ROAD 119
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-9384
Practice Address - Country:US
Practice Address - Phone:419-689-1865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-17
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities