Basic Information
| Provider Information | |||||||||
| NPI: | 1104944339 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROSSROADS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10373 GLENWAY DR APT 207 | ||||||||
| Address2: | |||||||||
| City: | TWINSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440877902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304053317 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8445 MUNSON RD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440602410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402551700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 4402551700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | E.0007485 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.