Provider Demographics
NPI:1376518902
Name:CORNELL ABRAXAS GROUP, LLC
Entity Type:Organization
Organization Name:CORNELL ABRAXAS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VOGT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-747-0881
Mailing Address - Street 1:2775 STATE ROUTE 39
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-9466
Mailing Address - Country:US
Mailing Address - Phone:419-747-3322
Mailing Address - Fax:419-747-0067
Practice Address - Street 1:2775 STATE ROUTE 39
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-9466
Practice Address - Country:US
Practice Address - Phone:419-747-3322
Practice Address - Fax:381-657-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-17
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0680261QM0801X
OHFACSIS 2563245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0063924Medicaid
OH2876928Medicaid
OH2094362Medicaid