Healthcare Provider Details

I. General information

NPI: 1336641968
Provider Name (Legal Business Name): JAMES EDWARD MONFORT LCDCIII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N MAIN ST
LIMA OH
45801-4434
US

IV. Provider business mailing address

1937 WENDELL AVE
LIMA OH
45805-3162
US

V. Phone/Fax

Practice location:
  • Phone: 419-234-1174
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number021379
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierNONE
Identifier TypeOTHER
Identifier State
Identifier IssuerNONE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: