Provider Demographics
NPI:1093816209
Name:BEECH BROOK
Entity Type:Organization
Organization Name:BEECH BROOK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:REX
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:216-831-2255
Mailing Address - Street 1:3737 LANDER RD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5712
Mailing Address - Country:US
Mailing Address - Phone:216-831-2255
Mailing Address - Fax:216-831-0436
Practice Address - Street 1:3737 LANDER ROAD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124
Practice Address - Country:US
Practice Address - Phone:216-831-2255
Practice Address - Fax:216-831-0436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12773251S00000X
OH208261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid
OH12773OtherODADAS PROVIDER CERTIFICATION
OH10205Medicare UPIN