Basic Information
| Provider Information | |||||||||
| NPI: | 1538115308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CATHOLIC CHARITIES SERVICES CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CATHOLIC CHARITIES SERVICES OF MEDINA COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 246 NORTHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442561533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307239615 | ||||||||
| FaxNumber: | 3307648795 | ||||||||
| Practice Location | |||||||||
| Address1: | 246 NORTHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442561533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307239615 | ||||||||
| FaxNumber: | 3307648795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOLL | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4408435501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | X | Agencies | Case Management | 261QM0801X | X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X | X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | Q081049 | 01 | OH | HOMETOWN HEALTH NETWORK | OTHER | 10063 | 05 | OH | MEDICAID | 341318421-007 | 01 | OH | MEDICAL MUTUAL | OTHER |