Basic Information
| Provider Information | |||||||||
| NPI: | 1215295811 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECIALIZED ALTERNATIVES FOR FAMILIES AND YOUTH OF OHIO, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SAFY OF OHIO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10100 ELIDA RD | ||||||||
| Address2: | |||||||||
| City: | DELPHOS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458339056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196958010 | ||||||||
| FaxNumber: | 4196950004 | ||||||||
| Practice Location | |||||||||
| Address1: | 10100 ELIDA RD | ||||||||
| Address2: | |||||||||
| City: | DELPHOS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458339056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196958010 | ||||||||
| FaxNumber: | 4196950004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2012 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP OF TREATMENT & CLINICAL S | ||||||||
| AuthorizedOfficialTelephone: | 4196958010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 10578 | 05 | OH | MEDICAID | 2847496 | 05 | OH | MEDICAID | 10331 | 05 | OH | MEDICAID |