Basic Information
| Provider Information | |||||||||
| NPI: | 1689284093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEWALT | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8295 PEBBLE CREEK CT | ||||||||
| Address2: | |||||||||
| City: | CHAGRIN FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440234866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164084649 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12557 RAVENWOOD DR | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440249009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402853568 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2020 | ||||||||
| LastUpdateDate: | 08/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C.1700329 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.