Basic Information
Provider Information | |||||||||
NPI: | 1760749444 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | A RENEWED MIND | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | A CITY OF COMPASSION DEVELOPMENT CORPORATION | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 885 COMMERCE DR | ||||||||
Address2: |   | ||||||||
City: | PERRYSBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 435515268 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193301060 | ||||||||
FaxNumber: | 4199316764 | ||||||||
Practice Location | |||||||||
Address1: | 1832 ADAMS ST | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 43604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197209247 | ||||||||
FaxNumber: | 4194227801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2012 | ||||||||
LastUpdateDate: | 02/15/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAMANN | ||||||||
AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 4193305115 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   | OH | N |   | Agencies | Community/Behavioral Health |   | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.