=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003498585
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I'M YOUR THERAPIST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2021
-----------------------------------------------------
Last Update Date | 04/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1715 INDIAN WOOD CIR STE 200
-----------------------------------------------------
City | MAUMEE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43537-4055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-339-8531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4397 FANGBONER RD
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-9360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-339-8531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DIANA ORNS-GRANT
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 269-339-8531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------