MEDICARE: TELOS FOUNDATION INC

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	1041C0700X	Clinical Social Worker	I.0002803.SUPV	OH

General Provider Information

NPI Number	:	1194956383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TELOS FOUNDATION INC

Provider Business Mailing Address
First Line	:	1875 N RIDGE RD E
Second Line	:	SUITE K
City	:	LORAIN
State	:	OH
Zip	:	44055-3371
Country	:	US
Telephone Number	:	440-277-1112
Fax Number	:	440-277-1109

Provider Business Practice Location Address
First Line	:	1875 N RIDGE RD E
Second Line	:	SUITE K
City	:	LORAIN
State	:	OH
Zip	:	44055-3371
Country	:	US
Telephone Number	:	440-277-1112
Fax Number	:	440-277-1109

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. WILLIAM F. VANEK
Credential	:	MSSA, LISW-S
Telephone Number	:	440-277-1112

Provider Enumeration Date	:	08/05/2009
Last Update Date	:	09/02/2010

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Directions to “TELOS FOUNDATION INC ” Practice Location

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