Basic Information
| Provider Information | |||||||||
| NPI: | 1669731246 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY LIFE COUNSELING & PSYCHIATRIC SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197749969 | ||||||||
| FaxNumber: | 4197565642 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197749969 | ||||||||
| FaxNumber: | 4197565642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2012 | ||||||||
| LastUpdateDate: | 05/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | COCHRAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4197749969 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2864575 | 05 | OH | MEDICAID |