Basic Information
| Provider Information | |||||||||
| NPI: | 1932333655 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILD AND ADOLESCENT BEHAVIORAL HEALTH | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 919 2ND ST NE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447041132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304547917 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 919 2ND ST NE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447041132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304547917 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2009 | ||||||||
| LastUpdateDate: | 05/08/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | SUZANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | TRAINED OTHER | ||||||||
| AuthorizedOfficialTelephone: | 3304547917 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | B.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.