Provider Demographics
NPI:1568418424
Name:CATHOLIC CHARITIES SERVICES CORPORATION
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES SERVICES CORPORATION
Other - Org Name:CATHOLIC CHARITIES SERVICES OF LAKE COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-843-5501
Mailing Address - Street 1:8 N STATE ST
Mailing Address - Street 2:SUITE 455
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3955
Mailing Address - Country:US
Mailing Address - Phone:440-946-7264
Mailing Address - Fax:440-953-1608
Practice Address - Street 1:8 N STATE ST
Practice Address - Street 2:SUITE 455
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3955
Practice Address - Country:US
Practice Address - Phone:440-946-7264
Practice Address - Fax:440-953-1608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0375261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH006853Medicare UPIN
OH9289502Medicare ID - Type UnspecifiedMEDICARE