Basic Information
| Provider Information | |||||||||
| NPI: | 1083843031 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE TOLEDO HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CULLEN CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SEAGATE # 800 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 4198247359 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 W CENTRAL AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192917919 | ||||||||
| FaxNumber: | 4194793272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2009 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCUNE | ||||||||
| AuthorizedOfficialFirstName: | LORRAINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5675851964 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE TOLEDO HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E0005120 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC0700X | 5415 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8822662 | 05 | OH | MEDICAID |