Provider Demographics
NPI:1720672876
Name:COBLENTZ, JULISSA J
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:J
Last Name:COBLENTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 FORLOW ST
Mailing Address - Street 2:
Mailing Address - City:MILLERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44654-1001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 S CLAY ST STE 101
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:OH
Practice Address - Zip Code:44654-1329
Practice Address - Country:US
Practice Address - Phone:330-275-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.15011871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical