Basic Information
| Provider Information | |||||||||
| NPI: | 1972550010 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CATHOLIC CHARITIES CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CATHOLIC CHARITIES - PARMADALE MH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6753 STATE RD | ||||||||
| Address2: | |||||||||
| City: | PARMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441344517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408435615 | ||||||||
| FaxNumber: | 4408431633 | ||||||||
| Practice Location | |||||||||
| Address1: | 6753 STATE RD | ||||||||
| Address2: | |||||||||
| City: | PARMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441344517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408435615 | ||||||||
| FaxNumber: | 4408431633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 01/17/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GAREAU | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2163342901 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 320800000X | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 07099 | 05 | OH | MEDICAID |