Healthcare Provider Details

I. General information

NPI: 1487636965
Provider Name (Legal Business Name): NORTH SHORE PSYCHOLOGICAL SERVICES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W PROSPECT RD SUITE 124
ASHTABULA OH
44004-5830
US

IV. Provider business mailing address

355 W PROSPECT RD STE 124
ASHTABULA OH
44004-5830
US

V. Phone/Fax

Practice location:
  • Phone: 440-992-1144
  • Fax: 440-998-1996
Mailing address:
  • Phone: 440-992-1144
  • Fax: 440-998-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID L HAUSMAN
Title or Position: TREASURER
Credential:
Phone: 440-992-1144