Provider Demographics
NPI:1851871677
Name:IMPACT THERAPY, LLC
Entity Type:Organization
Organization Name:IMPACT THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:OATS
Authorized Official - Suffix:
Authorized Official - Credentials:LICDC-CS
Authorized Official - Phone:419-349-6011
Mailing Address - Street 1:3450 W CENTRAL AVE STE 354
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1418
Mailing Address - Country:US
Mailing Address - Phone:419-407-5578
Mailing Address - Fax:844-272-8238
Practice Address - Street 1:3450 W CENTRAL AVE STE 354
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1418
Practice Address - Country:US
Practice Address - Phone:419-407-5578
Practice Address - Fax:844-272-8238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01-7629101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01-7629OtherOHIO MENTAL HEALTH AND ADDICTION SERVICES BOARD
OH0301404Medicaid
OH0115549Medicaid