Basic Information
| Provider Information | |||||||||
| NPI: | 1760741656 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIANA COUNTY MENTAL HEALTH CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 429 | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444320429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304249573 | ||||||||
| FaxNumber: | 3304240877 | ||||||||
| Practice Location | |||||||||
| Address1: | 40722 STATE ROUTE 154 | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444328500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304249573 | ||||||||
| FaxNumber: | 3304240877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 11/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | SIKORSZKY | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3304247761 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 2504 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 2863905 | 05 | OH | MEDICAID |