Healthcare Provider Details

I. General information

NPI: 1174604771
Provider Name (Legal Business Name): ELVIN B COBLENTZ PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 TR 359
BERLIN OH
44610
US

IV. Provider business mailing address

PO BOX 158
BERLIN OH
44610-0158
US

V. Phone/Fax

Practice location:
  • Phone: 330-893-2100
  • Fax: 330-893-2100
Mailing address:
  • Phone: 330-893-2100
  • Fax: 330-893-3732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4532
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: