Provider Demographics
NPI:1558403451
Name:RAVENWOOD MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:RAVENWOOD MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KORINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC-TEMP
Authorized Official - Phone:440-285-3568
Mailing Address - Street 1:118 GREENCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-3442
Mailing Address - Country:US
Mailing Address - Phone:216-587-5935
Mailing Address - Fax:
Practice Address - Street 1:12557 RAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9009
Practice Address - Country:US
Practice Address - Phone:440-285-3568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0500215.TEMP251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health