Basic Information
| Provider Information | |||||||||
| NPI: | 1700064870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEHAVIORAL CONNECTIONS OF WOOD COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 W GYPSY LANE RD | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434024572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193525387 | ||||||||
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| Practice Location | |||||||||
| Address1: | 320 W GYPSY LANE RD | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434024572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193525387 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2008 | ||||||||
| LastUpdateDate: | 01/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | GOLDBERG | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4193525387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | S28711 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 29968067400 | 01 | OH | OHIO BWC | OTHER |