Provider Demographics
NPI:1669968103
Name:ILIJEVSKI, JOHNNY (QMHS)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:ILIJEVSKI
Suffix:
Gender:M
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6662 STATE ROUTE 43
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-6137
Mailing Address - Country:US
Mailing Address - Phone:330-956-7182
Mailing Address - Fax:
Practice Address - Street 1:6662 STATE ROUTE 43
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-6137
Practice Address - Country:US
Practice Address - Phone:330-956-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health