Basic Information
| Provider Information | |||||||||
| NPI: | 1568722171 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE CENTER FOR INDIVIDUAL & FAMILY SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CATALYST LIFE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 741 SCHOLL RD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197561717 | ||||||||
| FaxNumber: | 4197745955 | ||||||||
| Practice Location | |||||||||
| Address1: | 741 SCHOLL RD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197561717 | ||||||||
| FaxNumber: | 4197745955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2012 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4197746705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 13000 | OH | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QR0405X | 04158 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 2916830 | 05 | OH | MEDICAID | 04158 | 01 | OH | MACSIS | OTHER |