Basic Information
| Provider Information | |||||||||
| NPI: | 1902202609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GADOUA | ||||||||
| FirstName: | JOLINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 NORTHWEST AVE | ||||||||
| Address2: | |||||||||
| City: | TALLMADGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442781808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302560135 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 NORTHWEST AVE | ||||||||
| Address2: | |||||||||
| City: | TALLMADGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302560135 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2014 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | S.1303268 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | I.1800936 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | I.1800936 | 01 | OH | COUNSELING, SOCIAL WORK, MARRIAGE AND FAMILY THERAPIST BOARD | OTHER |