Provider Demographics
NPI:1619798774
Name:DEWALT, HARRISON (LSW)
Entity type:Individual
Prefix:
First Name:HARRISON
Middle Name:
Last Name:DEWALT
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 BLUE LOCUST DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-2302
Mailing Address - Country:US
Mailing Address - Phone:419-545-1164
Mailing Address - Fax:
Practice Address - Street 1:2775 STATE ROUTE 39
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-9466
Practice Address - Country:US
Practice Address - Phone:419-747-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.190266101YA0400X
OHS.2511830104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)