=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164362810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDEN SHORES COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2026
-----------------------------------------------------
Last Update Date | 03/31/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4074 BROADWAY AVE NE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44641-9311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-205-4021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4074 BROADWAY AVE NE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44641-9311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-205-4021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/COUNSELOR
-----------------------------------------------------
Name | DANIEL DOLAK
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 330-284-6052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------