Provider Demographics
NPI:1124370812
Name:MIAMI COUNTY RECOVERY COUNCIL
Entity Type:Organization
Organization Name:MIAMI COUNTY RECOVERY COUNCIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEMICAL DEPENDENCY COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGT
Authorized Official - Suffix:
Authorized Official - Credentials:BS, LCDCIII
Authorized Official - Phone:937-335-4543
Mailing Address - Street 1:1059 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1433
Mailing Address - Country:US
Mailing Address - Phone:937-335-4543
Mailing Address - Fax:937-339-8371
Practice Address - Street 1:1059 N MARKET ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1433
Practice Address - Country:US
Practice Address - Phone:937-335-4543
Practice Address - Fax:937-339-8371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH081083251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2901051Medicaid