Provider Demographics
NPI:1518084789
Name:MAHONING COUNTY BOARD OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILI
Entity Type:Organization
Organization Name:MAHONING COUNTY BOARD OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, MSW
Authorized Official - Phone:330-797-2828
Mailing Address - Street 1:4791 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-5115
Mailing Address - Country:US
Mailing Address - Phone:330-797-2825
Mailing Address - Fax:330-797-2843
Practice Address - Street 1:4791 WOODRIDGE DR
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-5115
Practice Address - Country:US
Practice Address - Phone:330-797-2825
Practice Address - Fax:330-797-2843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0776110Medicaid