Basic Information
| Provider Information | |||||||||
| NPI: | 1811204977 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINORITY BEHAVIORAL HEALTH GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MBHG | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1293 COPLEY RD | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443202766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303741199 | ||||||||
| FaxNumber: | 3303740151 | ||||||||
| Practice Location | |||||||||
| Address1: | 1293 COPLEY RD | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443202766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303741199 | ||||||||
| FaxNumber: | 3303740151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2010 | ||||||||
| LastUpdateDate: | 10/05/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHILMORE-STROUD | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3303741199 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 101YM0800X | 05 | OH | MEDICAID | 101YM0800X | 01 | OH | ALL PRIVATE INSURANCES | OTHER |