Provider Demographics
NPI:1972277150
Name:UNTCH, DESIREE D (LISW-S)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:D
Last Name:UNTCH
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 1:6160 HILLFIELD ST NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-6414
Mailing Address - Country:US
Mailing Address - Phone:330-338-6607
Mailing Address - Fax:
Practice Address - Street 1:55 S MILLER RD STE LL2
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4170
Practice Address - Country:US
Practice Address - Phone:330-836-8370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700636104100000X
1041C0700X
OHI.2203787-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty