UPI (Provider ID): 3455
Change Report (if Any):

Short Name: WESTERN RESERVE

Long Name 1: WESTERN RESERVE COUNSELING
Long Name 2: SERVICES

Address 1: ONE VICTORIA SQUARE
Address 2: SUITE 105

City: PAINESVILLE
Zip Code: 44077
County: LAKE

Contact: SHARON BAKER
Title: ADM
Phone: 4403528954
FAX: 4403520351

Vendor: 3455

Reports Status: CLAIMS/NO

MACSIS Last Update Date: 11/29/2011

File Produced: 19MAY2012