Healthcare Provider Details

I. General information

NPI: 1205259934
Provider Name (Legal Business Name): DALLAS WINROD ED.S, NCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 DELAWARE DR
GNADENHUTTEN OH
44629-9706
US

IV. Provider business mailing address

50 DELAWARE DR
GNADENHUTTEN OH
44629-9706
US

V. Phone/Fax

Practice location:
  • Phone: 740-561-4021
  • Fax:
Mailing address:
  • Phone: 740-561-4021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH3028746
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: