Basic Information
| Provider Information | |||||||||
| NPI: | 1346412061 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHAWNEE MENTAL HEALTH INC | ||||||||
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| OtherOrganizationName: | SHAWNEE MENTAL HEALTH INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456623944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403547702 | ||||||||
| FaxNumber: | 7403531662 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456623944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403547702 | ||||||||
| FaxNumber: | 7403531662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2008 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOLSTEIN | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7403547702 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2475629 | 05 | OH | MEDICAID |