Provider Demographics
NPI:1417311473
Name:MONTGOMERY COUNTY BOARD OF DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY BOARD OF DEVELOPMENTAL DISABILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORTNEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:937-457-2870
Mailing Address - Street 1:160 COPPERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1263
Mailing Address - Country:US
Mailing Address - Phone:937-475-1734
Mailing Address - Fax:
Practice Address - Street 1:580 CALUMET LN
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-8014
Practice Address - Country:US
Practice Address - Phone:937-457-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1001000251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5700012Medicaid