Basic Information
| Provider Information | |||||||||
| NPI: | 1972164168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCHER | ||||||||
| FirstName: | MARYSSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1925 HAYES AVE | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448704737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195575177 | ||||||||
| FaxNumber: | 4195575179 | ||||||||
| Practice Location | |||||||||
| Address1: | 6150 PARK SQUARE DR STE B | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440534153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409843882 | ||||||||
| FaxNumber: | 4409843883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2019 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.