Basic Information
| Provider Information | |||||||||
| NPI: | 1932510385 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARBOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3909 WOODLEY RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436061169 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3909 WOODLEY RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436061169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197253330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2014 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | JABLONSKI | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4195171758 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 0064938 | 05 | OH | MEDICAID | 2341639 | 05 | OH | MEDICAID |