Basic Information
| Provider Information | |||||||||
| NPI: | 1902084528 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | A RENEWED MIND | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | A CITY OF COMPASSION | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 COMMERCE DR. | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435515268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193301050 | ||||||||
| FaxNumber: | 4199386820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1832 ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197209586 | ||||||||
| FaxNumber: | 4197209588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAMANN | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4193305115 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 12679 | OH | N | Agencies | Community/Behavioral Health | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 12679 | 01 | OH | ODADAS UPI NUMBER | OTHER | 2963995 | 05 | OH | MEDICAID |