Healthcare Provider Details

I. General information

NPI: 1194237925
Provider Name (Legal Business Name): SEAN LOLLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 S CENTER ST
SPRINGFIELD OH
45506-2209
US

IV. Provider business mailing address

1101 E HIGH ST
SPRINGFIELD OH
45505-1121
US

V. Phone/Fax

Practice location:
  • Phone: 937-328-5300
  • Fax: 937-322-4900
Mailing address:
  • Phone: 937-328-5300
  • Fax: 937-322-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.161630
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: