Healthcare Provider Details

I. General information

NPI: 1215770151
Provider Name (Legal Business Name): FALLEN TIMBERS HOLISTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7947 STITT RD
WATERVILLE OH
43566-9817
US

IV. Provider business mailing address

7947 STITT RD
WATERVILLE OH
43566-9817
US

V. Phone/Fax

Practice location:
  • Phone: 419-460-1103
  • Fax:
Mailing address:
  • Phone: 419-460-1103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JEFFERY HOWELL
Title or Position: CO-OWNER
Credential: LPCC-S
Phone: 419-280-4841