Healthcare Provider Details

I. General information

NPI: 1205197027
Provider Name (Legal Business Name): PHYLLIS SUE GEORGE L.M.T, STNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1137 BAY CIRCLE ST
LIMA OH
45801-2411
US

IV. Provider business mailing address

1137 BAY CIRCLE
LIMA OH
45801
US

V. Phone/Fax

Practice location:
  • Phone: 419-230-1694
  • Fax:
Mailing address:
  • Phone: 419-230-1694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number401227960411
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number33 018370
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: