Provider Demographics
NPI:1043398506
Name:FRY, TODD A (LISW)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:A
Last Name:FRY
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 S TRIMBLE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906
Mailing Address - Country:US
Mailing Address - Phone:419-756-9975
Mailing Address - Fax:419-756-1405
Practice Address - Street 1:605 S TRIMBLE RD SUITE D
Practice Address - Street 2:LIFE STEPS INC
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906
Practice Address - Country:US
Practice Address - Phone:419-756-9975
Practice Address - Fax:419-756-1405
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI5386104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3417125562A15OtherMAGELLAN