Basic Information
| Provider Information | |||||||||
| NPI: | 1902275340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEROGIORGIS-SHAFFER | ||||||||
| FirstName: | KYRIAKI | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | SHAFFER | ||||||||
| OtherFirstName: | KYRIAKI | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | DEPT 781625 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
| FaxNumber: | 6143552220 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 BUTTERFLY GARDENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432157508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143557150 | ||||||||
| FaxNumber: | 6143557855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | M.1500015 | OH | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | F1700003 | OH | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |