Provider Demographics
NPI:1710106984
Name:MAILLOUX, OPHELIA (LISW-S)
Entity Type:Individual
Prefix:MRS
First Name:OPHELIA
Middle Name:
Last Name:MAILLOUX
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W. THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2633
Mailing Address - Country:US
Mailing Address - Phone:419-526-7869
Mailing Address - Fax:419-522-0493
Practice Address - Street 1:600 W. THIRD STREET
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2633
Practice Address - Country:US
Practice Address - Phone:419-522-6191
Practice Address - Fax:419-522-0493
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
OHI.00010288104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist