Provider Demographics
NPI:1710187364
Name:MARYMOUNT BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:MARYMOUNT BEHAVIORAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSIN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:216-986-1169
Mailing Address - Street 1:6000 W CREEK RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2139
Mailing Address - Country:US
Mailing Address - Phone:216-986-1169
Mailing Address - Fax:216-986-1016
Practice Address - Street 1:6000 W CREEK RD
Practice Address - Street 2:SUITE 20
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2139
Practice Address - Country:US
Practice Address - Phone:216-986-1169
Practice Address - Fax:216-986-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-227101YS0200X
OHI-21641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty