Provider Demographics
NPI:1407820343
Name:YORK AVENUE CHURCH OF GOD TREATMENT CENTER
Entity Type:Organization
Organization Name:YORK AVENUE CHURCH OF GOD TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LICDC
Authorized Official - Phone:330-392-4199
Mailing Address - Street 1:1228 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-2780
Mailing Address - Country:US
Mailing Address - Phone:330-392-4199
Mailing Address - Fax:330-392-4904
Practice Address - Street 1:1228 W MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2780
Practice Address - Country:US
Practice Address - Phone:330-392-4199
Practice Address - Fax:330-392-4904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6949251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH06949OtherUCI NUMBER