MEDICARE: SOUTHWESTERN OHIO BEHAVIORAL HEALTH,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	103TC0700X	Clinical Psychologist	4664	OH

General Provider Information

NPI Number	:	1376631713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWESTERN OHIO BEHAVIORAL HEALTH,LLC

Provider Business Mailing Address
First Line	:	PO BOX 41158
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45441-0158
Country	:	US
Telephone Number	:	937-435-8864
Fax Number	:	937-435-8264

Provider Business Practice Location Address
First Line	:	35 IRONGATE PARK DR
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-4616
Country	:	US
Telephone Number	:	937-435-8864
Fax Number	:	937-435-8264

Authorized Official
Title or Position	:	OWNER-CLINICAL PSYCHOLOGIST
Name	:	DR. KIMBERLY SHAFFER TATE
Credential	:	PSY.D
Telephone Number	:	937-435-8864

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	06/29/2011

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