| Sourceone | |
|
210 E Milltown Rd Suite B Wooster OH 44691-1246 | |
| (330) 345-0955 | |
| (330) 345-3420 |
| Full Name | Sourceone |
|---|---|
| Speciality | Clinic/Center |
| Location | 210 E Milltown Rd, Wooster, Ohio |
| Authorized Official Name and Position | Susan D. Buchwalter (PRESIDENT/CEO) |
| Authorized Official Contact | 3303450955 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Sourceone 210 E Milltown Rd Suite B Wooster OH 44691-1246 Ph: (330) 345-0955 | Sourceone 210 E Milltown Rd Suite B Wooster OH 44691-1246 Ph: (330) 345-0955 |
| NPI Number | 1447346564 |
|---|---|
| Provider Enumeration Date | 10/05/2006 |
| Last Update Date | 01/14/2008 |
| Medicare PECOS PAC ID | 8729988399 |
|---|---|
| Medicare Enrollment ID | O20040110000023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1447346564 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0850X | Clinic/center - Adult Mental Health | (Ohio) | Primary |
| 261QM0855X | Clinic/center - Adolescent And Children Mental Health | (Ohio) | Secondary |
| Provider Name | Charles F Gibson |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1528028073 PECOS PAC ID: 4789844739 Enrollment ID: I20120328000665 |
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