Healthcare Provider Details

I. General information

NPI: 1114702032
Provider Name (Legal Business Name): MORGAN ASHLEY MAXWELL CT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 MADISON ST
PORT CLINTON OH
43452-1937
US

IV. Provider business mailing address

930 CLINTON ST
FREMONT OH
43420-2110
US

V. Phone/Fax

Practice location:
  • Phone: 419-734-5535
  • Fax:
Mailing address:
  • Phone: 567-201-6341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.2304963-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC.2304963-TRNE
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2304963-TRNE
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2304963-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: