Provider Demographics
NPI:1134385669
Name:CORNELL ABRAXAS GROUP, LLC
Entity type:Organization
Organization Name:CORNELL ABRAXAS GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VOGT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-747-0881
Mailing Address - Street 1:2775 STATE ROUTE 39
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-9466
Mailing Address - Country:US
Mailing Address - Phone:419-347-3322
Mailing Address - Fax:419-747-0067
Practice Address - Street 1:2775 STATE ROUTE 39
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-9466
Practice Address - Country:US
Practice Address - Phone:419-347-3322
Practice Address - Fax:419-747-0067
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORNELL ABRAXAS GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-04
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0680320800000X
3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2876928Medicaid
OH0063924Medicaid
OH6967Medicaid