Provider Demographics
NPI:1144762337
Name:FATHERHOOD REVISITED
Entity Type:Organization
Organization Name:FATHERHOOD REVISITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:PETTIJOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-549-4172
Mailing Address - Street 1:PO BOX 12685
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-0685
Mailing Address - Country:US
Mailing Address - Phone:513-549-4172
Mailing Address - Fax:
Practice Address - Street 1:10925 REED HARTMAN HWY STE 310C
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-2842
Practice Address - Country:US
Practice Address - Phone:513-549-4172
Practice Address - Fax:513-586-0452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-06
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health