1396714473 NPI number — STATE OF OHIO DEPARTMENT OF MENTAL HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396714473 NPI number — STATE OF OHIO DEPARTMENT OF MENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF OHIO DEPARTMENT OF MENTAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WASHINGTON CO COMM MH SERVICES CSN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396714473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 E. BROAD ST
Provider Second Line Business Mailing Address:
11TH FLOOR - FISCAL ADMINISTRATION
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43215-3430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-466-6583
Provider Business Mailing Address Fax Number:
614-644-5331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 PUTNAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45750-2923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-374-6989
Provider Business Practice Location Address Fax Number:
740-432-7567
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FASONE
Authorized Official First Name:
TONYA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
FISCAL MANAGER
Authorized Official Telephone Number:
614-466-9930

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10355 . This is a "MACSIS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2452233 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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