=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205259934
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALLAS WINROD ED.S, NCSP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2014
-----------------------------------------------------
Last Update Date | 01/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 DELAWARE DR
-----------------------------------------------------
City | GNADENHUTTEN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44629-9706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-561-4021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 DELAWARE DR
-----------------------------------------------------
City | GNADENHUTTEN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44629-9706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-561-4021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | OH3028746
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------