Provider Demographics
NPI:1598723728
Name:MOUNDBUILDERS GUIDANCE CENTER, INC.
Entity Type:Organization
Organization Name:MOUNDBUILDERS GUIDANCE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:C
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-788-3400
Mailing Address - Street 1:8402 BLACKJACK ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-9193
Mailing Address - Country:US
Mailing Address - Phone:740-397-0442
Mailing Address - Fax:740-392-1814
Practice Address - Street 1:8402 BLACKJACK ROAD EXT
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9193
Practice Address - Country:US
Practice Address - Phone:740-397-0442
Practice Address - Fax:740-392-1814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2485734OtherRISPERDAL
OHMC-26Medicaid
OH0200008OtherMEDICARE CROSSOVER
OH0200008OtherMEDICARE CROSSOVER
OH9226892Medicare PIN