Basic Information
| Provider Information | |||||||||
| NPI: | 1245635549 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TALBOT CLINICAL SERVICES OF OHIO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2541 GEORGETOWN AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436134303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195097422 | ||||||||
| FaxNumber: | 4196910601 | ||||||||
| Practice Location | |||||||||
| Address1: | 3170 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436062945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5673167253 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2014 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | BRYANT | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4195097422 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MA, LICDC-CS | ||||||||
| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 101YP2500X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0208677 | 05 | OH | MEDICAID |