Basic Information
| Provider Information | |||||||||
| NPI: | 1336764539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOVILLE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | TOD | ||||||||
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| Credential: | CT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 GORDON ST | ||||||||
| Address2: | |||||||||
| City: | GIRARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444201707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2346000672 | ||||||||
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| Practice Location | |||||||||
| Address1: | 165 E PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444462352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305448005 | ||||||||
| FaxNumber: | 3305449379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2020 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.2002366-TRNE | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.