Basic Information
Provider Information | |||||||||
NPI: | 1508827932 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COLUMBIANA COUNTY MENTAL HEALTH CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE COUNSELING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40722 STATE ROUTE 154 | ||||||||
Address2: | PO BOX 429 | ||||||||
City: | LISBON | ||||||||
State: | OH | ||||||||
PostalCode: | 444328500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304249573 | ||||||||
FaxNumber: | 3304240877 | ||||||||
Practice Location | |||||||||
Address1: | 40722 STATE ROUTE 154 | ||||||||
Address2: |   | ||||||||
City: | LISBON | ||||||||
State: | OH | ||||||||
PostalCode: | 444328500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304249573 | ||||||||
FaxNumber: | 3304240877 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2006 | ||||||||
LastUpdateDate: | 02/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SIKORSZKY | ||||||||
AuthorizedOfficialFirstName: | ROGER | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3304247761 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 0118,2504 | OH | N |   | Agencies | Case Management |   | 261QM0850X | 0118,2504 | OH | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | 0118,2504 | OH | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | 0118,2504 | OH | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 0201696 | 05 | OH |   | MEDICAID | 1051 | 01 | OH | COMMUNITY MEDICAID | OTHER |