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General NPI Number Information
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NPI Number | 1619798774
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Entity Type | Individual
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Provider Name | HARRISON DEWALT LSW
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Gender | Male
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Dates
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Enumeration Date | 10/22/2024
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Last Update Date | 02/04/2025
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Provider Practice Location Address
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Address Line | 2775 STATE ROUTE 39
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City | SHELBY
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State | OH
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Zip | 44875-9466
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Country | US
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Telephone | 419-747-3322
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Fax |
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Provider Business Mailing Address
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Address Line | 1730 BLUE LOCUST DR
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City | MANSFIELD
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State | OH
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Zip | 44905-2302
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Country | US
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Telephone | 419-545-1164
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CDCA.190266
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | S.2511830
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License Number State | OH
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