Basic Information
| Provider Information | |||||||||
| NPI: | 1710106984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAILLOUX | ||||||||
| FirstName: | OPHELIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W. THIRD STREET | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195267869 | ||||||||
| FaxNumber: | 4195220493 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 W. THIRD STREET | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195226191 | ||||||||
| FaxNumber: | 4195220493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 08/01/2012 | ||||||||
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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 | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 104100000X | I.00010288 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.