Healthcare Provider Details

I. General information

NPI: 1528096583
Provider Name (Legal Business Name): LORI MCGONAGLE O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 HILLS AND DALES RD NW
CANTON OH
44708-1510
US

IV. Provider business mailing address

4650 HILLS AND DALES RD NW SUITE 100
CANTON OH
44708-6220
US

V. Phone/Fax

Practice location:
  • Phone: 330-477-9720
  • Fax:
Mailing address:
  • Phone: 330-477-9720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT01466
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: