Provider Demographics
NPI:1255047494
Name:NEW DESTINY TREATMENT CENTER MENTAL HEALTH AND SPECIAL SERVICES LLC
Entity type:Organization
Organization Name:NEW DESTINY TREATMENT CENTER MENTAL HEALTH AND SPECIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:BOLOIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:330-825-5202
Mailing Address - Street 1:6694 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:44216-9201
Mailing Address - Country:US
Mailing Address - Phone:330-825-5202
Mailing Address - Fax:330-825-5113
Practice Address - Street 1:6694 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OH
Practice Address - Zip Code:44216-9201
Practice Address - Country:US
Practice Address - Phone:330-825-5202
Practice Address - Fax:330-825-5113
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW DESTINY TREATMENT CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0425321Medicaid