Basic Information
| Provider Information | |||||||||
| NPI: | 1811966401 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF OHIO DEPARTMENT OF MENTAL HEALTH | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SB - SUMMIT BEHAVIORAL HEALTH CSN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 E. BROAD ST | ||||||||
| Address2: | 11TH FLOOR - FISCAL ADMINISTRATION | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432153430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144666583 | ||||||||
| FaxNumber: | 6146445331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 SUMMIT RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452372621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139483600 | ||||||||
| FaxNumber: | 5139483080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 01/29/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FASONE | ||||||||
| AuthorizedOfficialFirstName: | TONYA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | FISCAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6144669930 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | OH | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 10343 | 01 | OH | MACSIS | OTHER | 2589293 | 05 | OH | MEDICAID |