Basic Information
| Provider Information | |||||||||
| NPI: | 1962671768 | ||||||||
| 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 | ||||||||
| TelephoneNumber: | 4195841000 | ||||||||
| FaxNumber: | 4195841825 | ||||||||
| Practice Location | |||||||||
| Address1: | 4761 STATE ROUTE 29 | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458228216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195841000 | ||||||||
| FaxNumber: | 4195841825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | ENGLE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4195841000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2687874 | 05 | OH | MEDICAID |