Provider Demographics
NPI:1750851622
Name:SHAWNEE MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:SHAWNEE MENTAL HEALTH CENTER, INC.
Other - Org Name:DBA SHAWNEE FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-355-8686
Mailing Address - Street 1:901 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3944
Mailing Address - Country:US
Mailing Address - Phone:740-355-8686
Mailing Address - Fax:
Practice Address - Street 1:192 CHESTNUT RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:OH
Practice Address - Zip Code:45693-9584
Practice Address - Country:US
Practice Address - Phone:937-544-5400
Practice Address - Fax:740-353-1662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0339258Medicaid