Provider Demographics
NPI:1659833655
Name:GRACE BLOSSOMS BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:GRACE BLOSSOMS BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROVAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-354-0464
Mailing Address - Street 1:7628 SLATE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-8159
Mailing Address - Country:US
Mailing Address - Phone:614-354-0464
Mailing Address - Fax:
Practice Address - Street 1:7628 SLATE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-8159
Practice Address - Country:US
Practice Address - Phone:614-354-0464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-01
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0345877Medicaid