Healthcare Provider Details

I. General information

NPI: 1649337817
Provider Name (Legal Business Name): FORT MEIGS PSYCHOLOGICAL SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 COMMERCE DR
PERRYSBURG OH
43551-5228
US

IV. Provider business mailing address

975 COMMERCE DR
PERRYSBURG OH
43551-5228
US

V. Phone/Fax

Practice location:
  • Phone: 419-874-8257
  • Fax: 419-874-9960
Mailing address:
  • Phone: 419-874-8257
  • Fax: 419-874-9960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4836
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0002078
License Number StateOH

VIII. Authorized Official

Name: PATRICIA A. VAN KLEY
Title or Position: PRESIDENT
Credential: PHD
Phone: 419-874-8257