Basic Information
| Provider Information | |||||||||
| NPI: | 1528302270 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATHOLIC CHARITIES WAYNE COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9044 ONTARIO ST NW | ||||||||
| Address2: | |||||||||
| City: | MASSILLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446461660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307308119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 521 BEALL AVE | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446913589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302627836 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 11/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | HURDLE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3302627836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CATHOLIC DIOCESE OF CLEVELAND | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LISW-S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | S.1000446 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 12763 | 05 | OH | MEDICAID |