36D1053301 CLIA NUMBER - MAUMEE VALLEY GUIDANCE CENTER

Laboratory Demographics

CLIA Number: 36D1053301

Facility Name: MAUMEE VALLEY GUIDANCE CENTER

Facility Address:
211 BIEDE AVENUE
DEFIANCE, OH
ZIP 43512
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Facility Phone Number: 419 782-8856

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1639341589

Taxonomy: 103TP0016X - Psychologist
A licensed, doctoral-level psychologist authorized to prescribe and has undergone specialized education and training in preparation for prescriptive practice and has passed an examination accepted by the state board of psychology relevant to establishing competence for prescribing, and has received from the state board of psychology a current certificate granting prescriptive authority, which has not been revoked or suspended.

CLIA Record

Field Name	Field Value
CLIA Number	36D1053301
LAB Type	Practitioner Other
Facility Name	MAUMEE VALLEY GUIDANCE CENTER
Street	211 BIEDE AVENUE
City	DEFIANCE
State	OH
ZIP	43512
Phone	419 782-8856
CertificateType	4
CertificateEffectiveDate	4/20/2024
CertificateExpirationDate	4/19/2026
FacilityType	Waiver

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This page was last updated on: 4/23/2024