Provider Demographics
NPI:1093307654
Name:CROSSROADS HEALTH
Entity Type:Organization
Organization Name:CROSSROADS HEALTH
Other - Org Name:CROSSROADS LAKE COUNTY ADOLESCENT COUNSELING
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:IDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-255-1700
Mailing Address - Street 1:8445 MUNSON RD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-2410
Mailing Address - Country:US
Mailing Address - Phone:440-255-1700
Mailing Address - Fax:
Practice Address - Street 1:9220 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6412
Practice Address - Country:US
Practice Address - Phone:440-354-9924
Practice Address - Fax:877-242-9583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-05
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0435072Medicaid