MEDICARE: HIDDEN ROOTS MENTAL HEALTH OHIO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1578313631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIDDEN ROOTS MENTAL HEALTH OHIO

Provider Business Mailing Address
First Line	:	5725 DRAGON WAY STE 301
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45227-4519
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5725 DRAGON WAY STE 301
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45227-4519
Country	:	US
Telephone Number	:	513-407-7524
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JASMARY TINEO
Credential	:
Telephone Number	:	513-407-7524

Provider Enumeration Date	:	03/22/2024
Last Update Date	:	03/22/2024

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