Basic Information
| Provider Information | |||||||||
| NPI: | 1790032472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUNDATIONS BEHAVIORAL HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4761 STATE ROUTE 29 | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458228216 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4761 STATE ROUTE 29 | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458228216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195841000 | ||||||||
| FaxNumber: | 4195841825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2012 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | GABLE | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4195841000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LISW | ||||||||
| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0057776 | 05 | OH | MEDICAID |