Provider Demographics
NPI:1720583776
Name:SQUARE NORTH PRACTICE
Entity Type:Organization
Organization Name:SQUARE NORTH PRACTICE
Other - Org Name:GUESS PSYCHOLOGICAL SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GUESS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:419-630-5430
Mailing Address - Street 1:126 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1316
Mailing Address - Country:US
Mailing Address - Phone:419-630-5430
Mailing Address - Fax:419-754-2215
Practice Address - Street 1:126 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1316
Practice Address - Country:US
Practice Address - Phone:419-630-5430
Practice Address - Fax:419-754-2215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6910103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0065271Medicaid