Provider Demographics
NPI:1760797542
Name:CHAMBERLAIN FAMILY THERAPY
Entity Type:Organization
Organization Name:CHAMBERLAIN FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:CHAMBERLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LISW-S
Authorized Official - Phone:740-477-1700
Mailing Address - Street 1:P.O. BOX 1176
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113
Mailing Address - Country:US
Mailing Address - Phone:740-477-1700
Mailing Address - Fax:740-477-1746
Practice Address - Street 1:906 N. COURT ST. SUITE C
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113
Practice Address - Country:US
Practice Address - Phone:740-477-1700
Practice Address - Fax:740-477-1746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI9800-S104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========051OtherCARE SOURCE