Basic Information
| Provider Information | |||||||||
| NPI: | 1013274273 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-OHIO PSYCHOLOGICAL SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 STARRET ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431303993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406870042 | ||||||||
| FaxNumber: | 7406876677 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 STARRET ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431303993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406870042 | ||||||||
| FaxNumber: | 7406876677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2012 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7406870042 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 251S00000X | N | Agencies | Community/Behavioral Health | 101Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 2325844 | 05 | OH | MEDICAID |