Healthcare Provider Details

I. General information

NPI: 1013963065
Provider Name (Legal Business Name): SOUTH SUBURBAN MENTAL HEALTH GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 E SPRING VALLEY RD STE B
CENTERVILLE OH
45458-3803
US

IV. Provider business mailing address

180 E SPRING VALLEY RD STE B
CENTERVILLE OH
45458-3803
US

V. Phone/Fax

Practice location:
  • Phone: 937-291-1351
  • Fax: 937-291-1719
Mailing address:
  • Phone: 937-291-1351
  • Fax: 937-291-1719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35083573
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK A CURTIS
Title or Position: PRESIDENT
Credential: APRN, CNS
Phone: 937-291-1351