Provider Demographics
NPI:1164782017
Name:NOVA BEHAVIORAL HEALTH, INC.
Entity Type:Organization
Organization Name:NOVA BEHAVIORAL HEALTH, INC.
Other - Org Name:NOVA HOUSE ASSOCIATION, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:GORIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LSW, LPCC-SC
Authorized Official - Phone:937-253-1680
Mailing Address - Street 1:732 BECKMAN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410-2165
Mailing Address - Country:US
Mailing Address - Phone:937-253-1680
Mailing Address - Fax:937-253-8990
Practice Address - Street 1:732 BECKMAN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-2165
Practice Address - Country:US
Practice Address - Phone:937-253-1680
Practice Address - Fax:937-253-8990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10-2063320800000X
OH1407324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2942632Medicaid