Basic Information
| Provider Information | |||||||||
| NPI: | 1144470485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOFSTETTER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1012 ODNR MOHICAN 51 | ||||||||
| Address2: | |||||||||
| City: | PERRYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448649407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199940300 | ||||||||
| FaxNumber: | 4199940305 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 ODNR MOHICAN 51 | ||||||||
| Address2: | |||||||||
| City: | PERRYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199940300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E.0008406 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0227403 | 05 | OH | MEDICAID |