Basic Information
| Provider Information | |||||||||
| NPI: | 1184824344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BE HEALED FAMILY OUTREACH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUCCESS 1 SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 670 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441463642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404399250 | ||||||||
| FaxNumber: | 2166417330 | ||||||||
| Practice Location | |||||||||
| Address1: | 670 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441463642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404399250 | ||||||||
| FaxNumber: | 2166417330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIVERS | ||||||||
| AuthorizedOfficialFirstName: | MIN. JEROME | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2162244254 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPCC-S, LIMFT, CCDC1 | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 011102 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP1600X | E4292 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Pastoral | 101YP2500X | E4292 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | F120 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.