Basic Information
Provider Information | |||||||||
NPI: | 1841458791 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACHIEVEMENT CENTERS FOR CHILDREN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4255 NORTHFIELD RD | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND HILLS | ||||||||
State: | OH | ||||||||
PostalCode: | 441282811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162929700 | ||||||||
FaxNumber: | 2163784613 | ||||||||
Practice Location | |||||||||
Address1: | 4255 NORTHFIELD RD | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND HILLS | ||||||||
State: | OH | ||||||||
PostalCode: | 441282811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162929700 | ||||||||
FaxNumber: | 2163784613 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/28/2008 | ||||||||
LastUpdateDate: | 01/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BASILE | ||||||||
AuthorizedOfficialFirstName: | KELLY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING AND AR MGR | ||||||||
AuthorizedOfficialTelephone: | 2162929700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 2448453 | 01 | OH | MACSIS: 10360 | OTHER | 2448453 | 05 | OH |   | MEDICAID |