Basic Information
| Provider Information | |||||||||
| NPI: | 1568418424 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CATHOLIC CHARITIES SERVICES CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CATHOLIC CHARITIES SERVICES OF LAKE COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 N STATE ST | ||||||||
| Address2: | SUITE 455 | ||||||||
| City: | PAINESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440773955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409467264 | ||||||||
| FaxNumber: | 4409531608 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 N STATE ST | ||||||||
| Address2: | SUITE 455 | ||||||||
| City: | PAINESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440773955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409467264 | ||||||||
| FaxNumber: | 4409531608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOLL | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4408435501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 0375 | OH | X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | 0375 | OH | X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X | 0375 | OH | X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.