Basic Information
| Provider Information | |||||||||
| NPI: | 1508058736 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUCCESS 1 SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441463642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404399250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 670 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441463642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404399250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2007 | ||||||||
| LastUpdateDate: | 08/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | TONYA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4404399250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LIMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 0007152 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 031002 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | S0023943 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 0008746 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | F051 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11762402 | 01 | OH | CAQH | OTHER |