Provider Demographics
NPI:1396493185
Name:KINDRED SPIRIT BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:KINDRED SPIRIT BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:LODGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:234-466-0445
Mailing Address - Street 1:PO BOX 4036
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-0036
Mailing Address - Country:US
Mailing Address - Phone:330-271-6160
Mailing Address - Fax:
Practice Address - Street 1:3618 W MARKET ST # E15
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-2425
Practice Address - Country:US
Practice Address - Phone:234-466-0445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-11
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0478831Medicaid