Provider Demographics
NPI:1750781324
Name:STAUFFER, CHERYL (MSW LSW)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:STAUFFER
Suffix:
Gender:F
Credentials:MSW LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:WILLSHIRE
Mailing Address - State:OH
Mailing Address - Zip Code:45898-0102
Mailing Address - Country:US
Mailing Address - Phone:419-513-0428
Mailing Address - Fax:419-495-2320
Practice Address - Street 1:813 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-1303
Practice Address - Country:US
Practice Address - Phone:419-513-0428
Practice Address - Fax:419-238-3565
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1100689104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid