Provider Demographics
NPI:1902293632
Name:MCPHERON, DAVINA
Entity Type:Individual
Prefix:
First Name:DAVINA
Middle Name:
Last Name:MCPHERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OH
Mailing Address - Zip Code:44425-2207
Mailing Address - Country:US
Mailing Address - Phone:330-883-6409
Mailing Address - Fax:
Practice Address - Street 1:165 E PARK AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2352
Practice Address - Country:US
Practice Address - Phone:330-544-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.14510001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2847254Medicaid