Basic Information
Provider Information | |||||||||
NPI: | 1710956594 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STATE OF OHIO OFFICE OF BUDGET AND MANAGEMENT, STATE ACCOUNTING | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AP - SUPERVISED LIVING CSN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30 E. BROAD ST | ||||||||
Address2: | 11TH FLOOR - FISCAL ADMINISTRATION | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432153430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6144666583 | ||||||||
FaxNumber: | 6146445331 | ||||||||
Practice Location | |||||||||
Address1: | 2510 JOHN GLENN HWY | ||||||||
Address2: |   | ||||||||
City: | CAMBRIDGE | ||||||||
State: | OH | ||||||||
PostalCode: | 437259028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7404391371 | ||||||||
FaxNumber: | 7404327567 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2006 | ||||||||
LastUpdateDate: | 11/30/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FASONE | ||||||||
AuthorizedOfficialFirstName: | TONYA | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | FISCAL MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6144669930 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   | OH | Y |   | Agencies | Case Management |   |
ID Information
ID | Type | State | Issuer | Description | 10356 | 01 | OH | MACSIS | OTHER |