Basic Information
Provider Information | |||||||||
NPI: | 1811920697 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DARKE COUNTY MENTAL HEALTH CLINIC, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 895 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 453311913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9375481635 | ||||||||
FaxNumber: | 9375481500 | ||||||||
Practice Location | |||||||||
Address1: | 212 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 453311913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9375481635 | ||||||||
FaxNumber: | 9375481500 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2006 | ||||||||
LastUpdateDate: | 04/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOORE | ||||||||
AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
AuthorizedOfficialMiddleName: | K. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT - BOARD OF DIRECTORS | ||||||||
AuthorizedOfficialTelephone: | 9375486842 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   | OH | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 0959440 | 05 | OH |   | MEDICAID |