Provider Demographics
NPI:1821638172
Name:RYNEARSON, KATLYNN (LSW)
Entity Type:Individual
Prefix:
First Name:KATLYNN
Middle Name:
Last Name:RYNEARSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:KATLYNN
Other - Middle Name:
Other - Last Name:DOTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:1100 SHAWNEE ROAD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3529
Mailing Address - Country:US
Mailing Address - Phone:419-999-2010
Mailing Address - Fax:419-999-6284
Practice Address - Street 1:160 FOX ROAD
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891
Practice Address - Country:US
Practice Address - Phone:419-238-6655
Practice Address - Fax:419-238-6696
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.16000901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0386614Medicaid
OHS.1600090OtherLICENSED SOCIAL WORKER