Provider Demographics
NPI:1043489503
Name:MOUNDBUILDERS GUIDANCE CENTER, INC
Entity Type:Organization
Organization Name:MOUNDBUILDERS GUIDANCE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDELBLUTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-788-0244
Mailing Address - Street 1:65 MESSIMER DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1874
Mailing Address - Country:US
Mailing Address - Phone:740-522-8477
Mailing Address - Fax:
Practice Address - Street 1:65 MESSIMER DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1874
Practice Address - Country:US
Practice Address - Phone:740-522-8477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2485734Medicaid
9226892Medicare UPIN
OH2485734Medicaid