=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154953446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRUDIE LYNN NEELY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2020
-----------------------------------------------------
Last Update Date | 02/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5726 SOUTHWYCK BLVD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43614-1559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-708-0441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 445 TORRINGTON DR
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43615-5434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-266-9664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | OH1258944
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------