=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194956383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TELOS FOUNDATION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2009
-----------------------------------------------------
Last Update Date | 09/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1875 N RIDGE RD E SUITE K
-----------------------------------------------------
City | LORAIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44055-3371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-277-1112
-----------------------------------------------------
Fax | 440-277-1109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1875 N RIDGE RD E SUITE K
-----------------------------------------------------
City | LORAIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44055-3371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-277-1112
-----------------------------------------------------
Fax | 440-277-1109
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. WILLIAM F. VANEK
-----------------------------------------------------
Credential | MSSA, LISW-S
-----------------------------------------------------
Telephone | 440-277-1112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.0002803.SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------