MEDICARE: PSYCHOLOGICAL COUNSELING CENTER

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	852	OH

General Provider Information

NPI Number	:	1750520417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGICAL COUNSELING CENTER

Provider Business Mailing Address
First Line	:	3618 W MARKET ST
Second Line	:
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-2425
Country	:	US
Telephone Number	:	330-815-0436
Fax Number	:

Provider Business Practice Location Address
First Line	:	3618 W MARKET ST
Second Line	:
City	:	FAIRLAWN
State	:	OH
Zip	:	44333-2425
Country	:	US
Telephone Number	:	330-815-0436
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEVEN J DAVIS
Credential	:	PH.D.
Telephone Number	:	330-815-0436

Provider Enumeration Date	:	02/19/2009
Last Update Date	:	02/19/2009

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