Healthcare Provider Details

I. General information

NPI: 1053872671
Provider Name (Legal Business Name): TERRANCE M POFFENBAUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 E MAUMEE ST # 107
ADRIAN MI
49221-2735
US

IV. Provider business mailing address

5939 DURBIN RD
SYLVANIA OH
43560-1556
US

V. Phone/Fax

Practice location:
  • Phone: 517-263-5810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0022416
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401005051
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: