Provider Demographics
NPI:1013963065
Name:SOUTH SUBURBAN MENTAL HEALTH GROUP
Entity Type:Organization
Organization Name:SOUTH SUBURBAN MENTAL HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:CURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CNS
Authorized Official - Phone:937-291-1351
Mailing Address - Street 1:180 E SPRING VALLEY RD
Mailing Address - Street 2:STE B
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3803
Mailing Address - Country:US
Mailing Address - Phone:937-291-1351
Mailing Address - Fax:937-291-1719
Practice Address - Street 1:180 E SPRING VALLEY RD
Practice Address - Street 2:STE B
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3803
Practice Address - Country:US
Practice Address - Phone:937-291-1351
Practice Address - Fax:937-291-1719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 1041C0700X, 2084P0804X, 364SP0807X, 364SP0808X
OH350835732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & AdolescentGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSO9358331Medicare ID - Type Unspecified