Basic Information
| Provider Information | |||||||||
| NPI: | 1255681805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CORNERSTONE OF RECOVERY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5003 HORIZONS DRIVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148890000 | ||||||||
| FaxNumber: | 6148461916 | ||||||||
| Practice Location | |||||||||
| Address1: | 5003 HORIZONS DRIVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148890000 | ||||||||
| FaxNumber: | 6148461916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2012 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | BONTA | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OHIO OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6148890000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE CORNERSTONE OF RECOVERY, INC. | ||||||||
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| AuthorizedOfficialCredential: | MSW, LICDC, LSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 12833 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 12833 | 01 | OH | OHIO DEPARTMENT OF ALCOHOL AND DRUG ADDICTION SERVICES | OTHER | 0075958 | 05 | OH | MEDICAID |