Basic Information
| Provider Information | |||||||||
| NPI: | 1821129230 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENGEBRETSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S EDWIN C MOSES BLVD, 4TH FLOOR NW BLDG | ||||||||
| Address2: | SAMARITAN BEHAVIORAL HEALTH INC | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454173424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377348333 | ||||||||
| FaxNumber: | 9377344343 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S EDWIN C MOSES BLVD | ||||||||
| Address2: | SAMARITAN BEHAVIORAL HEALTH, INC. | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454173424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193367501 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 11/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 4641 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 1108 | MT | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 94480 | 01 | NCC | OTHER |