Provider Demographics
NPI:1801208582
Name:MOHICAN YOUTH ACADEMY LLC
Entity type:Organization
Organization Name:MOHICAN YOUTH ACADEMY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-556-4616
Mailing Address - Street 1:1012 ODNR MOHICAN 51
Mailing Address - Street 2:
Mailing Address - City:PERRYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44864-9407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1012 ODNR MOHICAN 51
Practice Address - Street 2:
Practice Address - City:PERRYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44864-9407
Practice Address - Country:US
Practice Address - Phone:419-994-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH135193245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children