=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689713174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY J UDOLPH LISW-S, PCC-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 12/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 W MAIN ST SUITE 16
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44805-2282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-651-7669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1227 EASTBROOK DR
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44805-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-289-5372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | E0000325
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I0002798
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------