Basic Information
| Provider Information | |||||||||
| NPI: | 1558403451 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAVENWOOD MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 GREENCLIFF DR | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441463442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165875935 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12557 RAVENWOOD DR | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440249009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402853568 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GONGOS | ||||||||
| AuthorizedOfficialFirstName: | KORINNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4402853568 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.ED., LPC-TEMP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | C.0500215.TEMP | OH | Y | Agencies | Community/Behavioral Health |
No ID Information.