Healthcare Provider Details

I. General information

NPI: 1295167757
Provider Name (Legal Business Name): HEALING TRAILS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4317 STATE ROUTE 269 S
CASTALIA OH
44824-9354
US

IV. Provider business mailing address

143 COUNTY ROAD 242
FREMONT OH
43420-9234
US

V. Phone/Fax

Practice location:
  • Phone: 419-684-9750
  • Fax:
Mailing address:
  • Phone: 419-552-0647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number111018
License Number StateOH

VIII. Authorized Official

Name: CARRIE TORRES
Title or Position: COUNSELOR
Credential: LCDCIII
Phone: 419-552-0647