Healthcare Provider Details

I. General information

NPI: 1043665946
Provider Name (Legal Business Name): KAREN RONNETTA TRAIL LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6715 DORR ST
TOLEDO OH
43615
US

IV. Provider business mailing address

PO BOX 400
HOLLAND OH
43528
US

V. Phone/Fax

Practice location:
  • Phone: 419-868-1178
  • Fax: 419-868-1989
Mailing address:
  • Phone: 419-491-8828
  • Fax: 419-868-1989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS 0028531
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: