Healthcare Provider Details

I. General information

NPI: 1447346564
Provider Name (Legal Business Name): SOURCEONE GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E MILLTOWN RD SUITE B
WOOSTER OH
44691-1246
US

IV. Provider business mailing address

210 E MILLTOWN RD SUITE B
WOOSTER OH
44691-1246
US

V. Phone/Fax

Practice location:
  • Phone: 330-345-0955
  • Fax: 330-345-3420
Mailing address:
  • Phone: 330-345-0955
  • Fax: 330-345-3420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateOH

VIII. Authorized Official

Name: SUSAN D. BUCHWALTER
Title or Position: PRESIDENT/CEO
Credential: PH.D.
Phone: 330-345-0955