Provider Demographics
NPI:1629034830
Name:TRILLIUM FAMILY SOLUTIONS INC
Entity Type:Organization
Organization Name:TRILLIUM FAMILY SOLUTIONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:K
Authorized Official - Last Name:TRUBISKY
Authorized Official - Suffix:
Authorized Official - Credentials:MED EDS LPC-S
Authorized Official - Phone:330-454-7066
Mailing Address - Street 1:624 MARKET AVE N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1017
Mailing Address - Country:US
Mailing Address - Phone:330-454-7066
Mailing Address - Fax:330-454-9427
Practice Address - Street 1:624 MARKET AVE N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-1017
Practice Address - Country:US
Practice Address - Phone:330-454-7066
Practice Address - Fax:330-454-9427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251V00000X
OH524261Q00000X, 261QM0801X, 261QM0850X, 261QM0855X
OH10023261Q00000X
OH0215424503336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251V00000XAgenciesVoluntary or Charitable
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2098340Medicaid
OH10023OtherMACSIS UPI