Healthcare Provider Details

I. General information

NPI: 1689480352
Provider Name (Legal Business Name): THE OPEN TABLE CINCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 TENNESSEE AVE STE 204
CINCINNATI OH
45229-1044
US

IV. Provider business mailing address

5432 NORTHCREST LN APT 3
CINCINNATI OH
45247-6415
US

V. Phone/Fax

Practice location:
  • Phone: 513-518-5596
  • Fax:
Mailing address:
  • Phone: 513-900-7619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL COLLINS
Title or Position: CEO
Credential: LPCC
Phone: 513-518-5596