Healthcare Provider Details

I. General information

NPI: 1699459149
Provider Name (Legal Business Name): THOMAS EDWARD RATHBUN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 FAR HILLS AVE STE 205
KETTERING OH
45429-2346
US

IV. Provider business mailing address

402 WAYNE DR
FAIRBORN OH
45324-5417
US

V. Phone/Fax

Practice location:
  • Phone: 937-230-4661
  • Fax:
Mailing address:
  • Phone: 937-846-6663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2204757
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: