Provider Demographics
NPI:1295860724
Name:LICKING COUNTY BOARD OF MRDD
Entity Type:Organization
Organization Name:LICKING COUNTY BOARD OF MRDD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-349-6588
Mailing Address - Street 1:65 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-5013
Mailing Address - Country:US
Mailing Address - Phone:740-349-6588
Mailing Address - Fax:740-349-6595
Practice Address - Street 1:65 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5013
Practice Address - Country:US
Practice Address - Phone:740-349-6588
Practice Address - Fax:740-349-6595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4500016251B00000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0773051Medicaid