Basic Information
| Provider Information | |||||||||
| NPI: | 1902293632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCPHERON | ||||||||
| FirstName: | DAVINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 SCOTT ST | ||||||||
| Address2: | |||||||||
| City: | HUBBARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444252207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308836409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 165 E PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444462352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305448005 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2015 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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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.1451000 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2847254 | 05 | OH | MEDICAID |