Provider Demographics
NPI:1295772739
Name:WASDOVICH, JOSEPH R (PHD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:WASDOVICH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 EVERETT AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44302-1040
Mailing Address - Country:US
Mailing Address - Phone:216-433-2989
Mailing Address - Fax:
Practice Address - Street 1:72 EVERETT AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44302-1040
Practice Address - Country:US
Practice Address - Phone:216-433-2989
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5149103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2331793Medicaid
OHCP19781Medicare ID - Type Unspecified