Basic Information
| Provider Information | |||||||||
| NPI: | 1225508195 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAWNEE MENTAL HEALTH CENTER, INC. | ||||||||
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| OtherOrganizationName: | DBA SHAWNEE FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456623944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403558686 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 225 CARLTON DAVIDSON LN | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405336280 | ||||||||
| FaxNumber: | 7403531662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2018 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOLSTEIN | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7403558686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0339264 | 05 | OH | MEDICAID |