MEDICARE: PERRYSBURG THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	E1600096	OH
2	101YM0800X	Mental Health Counselor	C1300382	OH
3	101YM0800X	Mental Health Counselor	E1700029	OH
4	1041C0700X	Clinical Social Worker	I-000-5829-S	OH

General Provider Information

NPI Number	:	1073054219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERRYSBURG THERAPY LLC

Provider Business Mailing Address
First Line	:	830 W SOUTH BOUNDARY ST
Second Line	:	SUITE A
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-5238
Country	:	US
Telephone Number	:	419-931-3020
Fax Number	:	419-931-3022

Provider Business Practice Location Address
First Line	:	830 W SOUTH BOUNDARY ST
Second Line	:	SUITE A
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-5238
Country	:	US
Telephone Number	:	419-931-3020
Fax Number	:	419-931-3022

Authorized Official
Title or Position	:	OWNER
Name	:	CRAIG BURROW
Credential	:
Telephone Number	:	419-931-3020

Provider Enumeration Date	:	03/20/2017
Last Update Date	:	03/20/2017

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Directions to “PERRYSBURG THERAPY LLC ” Practice Location

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