Provider Demographics
NPI:1104664341
Name:SUPERTHERAPY
Entity type:Organization
Organization Name:SUPERTHERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:234-212-8254
Mailing Address - Street 1:59 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-3245
Mailing Address - Country:US
Mailing Address - Phone:234-212-8254
Mailing Address - Fax:
Practice Address - Street 1:59 S LAKE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-3245
Practice Address - Country:US
Practice Address - Phone:234-212-8254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty