Provider Demographics
NPI:1225087802
Name:PORTAGE PATH COMMUNITY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:PORTAGE PATH COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:PORTAGE PATH BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:YAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:330-253-3100
Mailing Address - Street 1:340 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44308-1529
Mailing Address - Country:US
Mailing Address - Phone:330-253-3100
Mailing Address - Fax:330-253-5248
Practice Address - Street 1:340 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1529
Practice Address - Country:US
Practice Address - Phone:330-253-3100
Practice Address - Fax:330-253-5248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2314561Medicaid
OH2314561Medicaid
OH9911777Medicare PIN
OH2314561Medicaid
OH9275071Medicare PIN
OH9911775Medicare PIN