Basic Information
| Provider Information | |||||||||
| NPI: | 1699730499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CATHOLIC CHARITIES COMMUNITY SERVICES CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CATHOLIC SERVICE LEAGUE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 812 BIRUTA STREET | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443071104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307627481 | ||||||||
| FaxNumber: | 3307627484 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443103017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307627481 | ||||||||
| FaxNumber: | 3307627484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | FINN | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3307627481 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DIRECTOR | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0162 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | 0162 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | CA9254301 | 01 | OH | GROUP MEDICARE | OTHER | MC441800 | 05 | OH | MEDICAID |