Basic Information
| Provider Information | |||||||||
| NPI: | 1588139125 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELIJAH | ||||||||
| FirstName: | ANTWON | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | I | ||||||||
| Credential: | QMHS/CMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S EDWIN C MOSES BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454173424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377348333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5050 MADISON RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452271491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132722800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2018 | ||||||||
| LastUpdateDate: | 06/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | S.1800373-TRNE | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | OH | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.