Basic Information
Provider Information | |||||||||
NPI: | 1356654941 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DARKE COUNTY MENTAL HEALTH CLINIC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 895 | ||||||||
Address2: | 212 E. MAIN ST | ||||||||
City: | GREENVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 453310895 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9375481635 | ||||||||
FaxNumber: | 9375481500 | ||||||||
Practice Location | |||||||||
Address1: | 3130 N COUNTY ROAD 25A | ||||||||
Address2: | SUITE 1000 | ||||||||
City: | TROY | ||||||||
State: | OH | ||||||||
PostalCode: | 453731337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373357166 | ||||||||
FaxNumber: | 9373399400 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2010 | ||||||||
LastUpdateDate: | 07/23/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONROE | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
AuthorizedOfficialTelephone: | 9375481635 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DARKE COUNTY MENTAL HEALTH CLINIC, INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 052 | OH | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 0959440 | 05 | OH |   | MEDICAID |