Healthcare Provider Details

I. General information

NPI: 1760634810
Provider Name (Legal Business Name): CRISIS INTERVENTION AND RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 MCKINLEY AVE NW
CANTON OH
44703-2463
US

IV. Provider business mailing address

832 MCKINLEY AVE NW
CANTON OH
44703-2463
US

V. Phone/Fax

Practice location:
  • Phone: 330-455-9407
  • Fax: 330-430-1288
Mailing address:
  • Phone: 330-455-9407
  • Fax: 330-430-1288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number061039
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI0800333
License Number StateOH

VIII. Authorized Official

Name: MR. BERNARD S JESIOLOWSKI
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD, PCCS
Phone: 330-452-9812