Basic Information
| Provider Information | |||||||||
| NPI: | 1053345975 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAVENWOOD MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12557 RAVENWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402852170 | ||||||||
| FaxNumber: | 4402852207 | ||||||||
| Practice Location | |||||||||
| Address1: | 12557 RAVENWOOD DR | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402853568 | ||||||||
| FaxNumber: | 4402854552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4402852170 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPCC-S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0801X | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 0576916 | 05 | OH | MEDICAID |