Provider Demographics
NPI:1407825474
Name:STATE OF OHIO DEPARTMENT OF MENTAL HEALTH
Entity Type:Organization
Organization Name:STATE OF OHIO DEPARTMENT OF MENTAL HEALTH
Other - Org Name:HB - CHILD AND FAMILY INTERVENTION TEAM CSN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FISCAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FASONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-466-9930
Mailing Address - Street 1:30 E. BROAD ST
Mailing Address - Street 2:11TH FLOOR - FISCAL ADMINISTRATION
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3430
Mailing Address - Country:US
Mailing Address - Phone:614-466-6583
Mailing Address - Fax:614-644-5331
Practice Address - Street 1:3076A REMSEN RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9225
Practice Address - Country:US
Practice Address - Phone:330-722-0750
Practice Address - Fax:330-723-0068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01565OtherMACSIS
OH01565OtherMACSIS