Provider Demographics
NPI:1770657579
Name:STANELUIS, KIM P (LISW LICDC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:P
Last Name:STANELUIS
Suffix:
Gender:F
Credentials:LISW LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-2150
Mailing Address - Country:US
Mailing Address - Phone:419-893-8432
Mailing Address - Fax:419-891-5403
Practice Address - Street 1:109 W WAYNE ST
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-2150
Practice Address - Country:US
Practice Address - Phone:419-893-8432
Practice Address - Fax:419-891-5403
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0001046104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW34041Medicare PIN