=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750704979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. PAUL A. DEARDORFF, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2014
-----------------------------------------------------
Last Update Date | 01/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4217 SMITH RD
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45212-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-871-7285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4217 SMITH RD
-----------------------------------------------------
City | NORWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45212-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-871-7285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE DIRECTOR
-----------------------------------------------------
Name | NICOLE LEISGANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-871-7285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6165
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------