MEDICARE: FAMILY SUCCESS CONSORTIUM INC

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	103T00000X	Psychologist	4512	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942520648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY SUCCESS CONSORTIUM INC

Provider Business Mailing Address
First Line	:	2650 MADISON RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45208-1332
Country	:	US
Telephone Number	:	513-772-9300
Fax Number	:	513-772-9302

Provider Business Practice Location Address
First Line	:	2650 MADISON RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45208-1332
Country	:	US
Telephone Number	:	513-772-9300
Fax Number	:	513-772-9302

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. MARK KENDAL EVANS
Credential	:	PSY.D.
Telephone Number	:	513-772-9300

Provider Enumeration Date	:	06/03/2010
Last Update Date	:	06/24/2010

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Directions to “FAMILY SUCCESS CONSORTIUM INC ” Practice Location

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