Basic Information
| Provider Information | |||||||||
| NPI: | 1134385669 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORNELL ABRAXAS GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ABRAXAS COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2775 STATE ROUTE 39 | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448759466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193473322 | ||||||||
| FaxNumber: | 4197470067 | ||||||||
| Practice Location | |||||||||
| Address1: | 2775 STATE ROUTE 39 | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448759466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193473322 | ||||||||
| FaxNumber: | 4197470067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VOGT | ||||||||
| AuthorizedOfficialFirstName: | JULIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4197470881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORNELL ABRAXAS GROUP, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 0680 | OH | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 3245S0500X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
ID Information
| ID | Type | State | Issuer | Description | 2876928 | 05 | OH | MEDICAID | 0063924 | 05 | OH | MEDICAID |