MEDICARE: CHRISTINE MARIE FARRIS LCDC III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	130635	OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	161681	OH

General Provider Information

NPI Number	:	1154848018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE MARIE FARRIS LCDC III

Provider Business Mailing Address
First Line	:	7665 WASHINGTON ST
Second Line	:
City	:	FLAT ROCK
State	:	OH
Zip	:	44828
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	65 SAINT FRANCIS AVE
Second Line	:
City	:	TIFFIN
State	:	OH
Zip	:	44883-3413
Country	:	US
Telephone Number	:	567-220-7018
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2017
Last Update Date	:	12/18/2023

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