Provider Demographics
NPI:1093475899
Name:KINDRED SPIRIT BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:KINDRED SPIRIT BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:LODGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:330-271-6160
Mailing Address - Street 1:PO BOX 4036
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-0036
Mailing Address - Country:US
Mailing Address - Phone:330-127-6160
Mailing Address - Fax:
Practice Address - Street 1:3618 W MARKET ST STE E15
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-2425
Practice Address - Country:US
Practice Address - Phone:330-271-6160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214582Medicaid