Basic Information
| Provider Information | |||||||||
| NPI: | 1114058674 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OHIOGUIDESTONE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | BEREA CHILDRENS HOME AND FAMILY SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 434 EASTLAND RD. | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440172058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608327 | ||||||||
| FaxNumber: | 4402348319 | ||||||||
| Practice Location | |||||||||
| Address1: | 5706 TURNEY RD | ||||||||
| Address2: | |||||||||
| City: | GARFIELD HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441253971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402606115 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 08/15/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEEGAN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4402608338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | I.0009197 | OH | N | Agencies | Case Management | 251S00000X | I.0009197 | OH | Y | Agencies | Community/Behavioral Health |
No ID Information.