Healthcare Provider Details

I. General information

NPI: 1144762337
Provider Name (Legal Business Name): FATHERHOOD REVISITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2016
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10925 REED HARTMAN HWY STE 310C
BLUE ASH OH
45242-2842
US

IV. Provider business mailing address

PO BOX 12685
CINCINNATI OH
45212-0685
US

V. Phone/Fax

Practice location:
  • Phone: 513-549-4172
  • Fax: 513-586-0452
Mailing address:
  • Phone: 513-549-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. KEISHA RENEE PETTIJOHN
Title or Position: CEO/FOUNDER
Credential:
Phone: 513-549-4172