=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669152088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED MEDICAL MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2023
-----------------------------------------------------
Last Update Date | 05/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5295 ASHLEY CIR
-----------------------------------------------------
City | AUSTINTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44515-1162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-227-8287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19917 TIMBERED ESTATES LN
-----------------------------------------------------
City | CARLINVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62626-3939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | CARRIE PUHALLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 440-371-3680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------