Provider Demographics
NPI:1730278441
Name:MONTGOMERY COUNTY BOARD OF MR/DD
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY BOARD OF MR/DD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCIAL MANAGEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PROULX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-837-9258
Mailing Address - Street 1:5450 SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-1450
Mailing Address - Country:US
Mailing Address - Phone:937-837-9200
Mailing Address - Fax:937-854-0492
Practice Address - Street 1:5450 SALEM AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-1450
Practice Address - Country:US
Practice Address - Phone:937-837-9200
Practice Address - Fax:937-854-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2741295Medicaid
OH0880337Medicaid
OH2568994Medicaid