Basic Information
| Provider Information | |||||||||
| NPI: | 1730567603 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOHICAN YOUTH ACADEMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1012 ODNR MOHICAN 51 | ||||||||
| Address2: | |||||||||
| City: | PERRYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448649407 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1012 ODNR MOHICAN 51 | ||||||||
| Address2: | |||||||||
| City: | PERRYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448649407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199940300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2015 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | BRUNO | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6145564616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 01-7531 | 01 | OH | OHIOMHAS | OTHER |