Provider Demographics
NPI:1487191656
Name:OHIO MENTOR, INC
Entity Type:Organization
Organization Name:OHIO MENTOR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DUKLES
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC-S
Authorized Official - Phone:216-318-6461
Mailing Address - Street 1:6200 ROCKSIDE WOODS BLVD N
Mailing Address - Street 2:SUITE 305
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2333
Mailing Address - Country:US
Mailing Address - Phone:440-525-1885
Mailing Address - Fax:216-525-1894
Practice Address - Street 1:6200 ROCKSIDE WOODS BLVD N
Practice Address - Street 2:SUITE 305
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2333
Practice Address - Country:US
Practice Address - Phone:440-525-1885
Practice Address - Fax:216-525-1894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-8251253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency