Basic Information
| Provider Information | |||||||||
| NPI: | 1013277516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TORRES | ||||||||
| FirstName: | MALERIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 781625 PO BOX 78000 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
| FaxNumber: | 6143550509 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 W SCHROCK RD | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430812874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558230 | ||||||||
| FaxNumber: | 6143558231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2012 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | C.1801595 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1473276 | 05 | OH | MEDICAID |