Basic Information
| Provider Information | |||||||||
| NPI: | 1831162817 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRISIS INTERVENTION AND RECOVERY CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 832 MCKINLEY AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447032463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304529812 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 832 MCKINLEY AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447032463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304529812 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 02/27/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JESIOLOWSKI | ||||||||
| AuthorizedOfficialFirstName: | BERNARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3304529812 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | 0203 | OH | Y | Agencies | Voluntary or Charitable |
ID Information
| ID | Type | State | Issuer | Description | 0201098 | 05 | OH | MEDICAID |