Basic Information
| Provider Information | |||||||||
| NPI: | 1487063699 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE VILLAGE NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17606 COSHOCTON RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430509218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403970533 | ||||||||
| FaxNumber: | 7403970350 | ||||||||
| Practice Location | |||||||||
| Address1: | 17606 COSHOCTON RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430509218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403970533 | ||||||||
| FaxNumber: | 7403970350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2014 | ||||||||
| LastUpdateDate: | 08/13/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRAH | ||||||||
| AuthorizedOfficialFirstName: | RANDA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7403970533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | S1450673 | OH | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.