Basic Information
| Provider Information | |||||||||
| NPI: | 1295212512 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLWELL BEHAVIORAL HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2845 BELL ST | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404549766 | ||||||||
| FaxNumber: | 7405886452 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 BELL ST | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404549766 | ||||||||
| FaxNumber: | 7405886452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2018 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FORAKER | ||||||||
| AuthorizedOfficialFirstName: | SUE ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7404549766 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BS | ||||||||
| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0301957 | 05 | OH | MEDICAID |