Basic Information
| Provider Information | |||||||||
| NPI: | 1699190041 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL COMMUNITY HEALTH BOARD | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 530 MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135592000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 530 MAXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135592000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2014 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MASSEY | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5135592000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LISW-S | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 080 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | MC21-12 | 05 | OH | MEDICAID |