Healthcare Provider Details

I. General information

NPI: 1205234572
Provider Name (Legal Business Name): MAPLE KNOLL OUTREACH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11275 SPRINGFIELD PIKE
CINCINNATI OH
45246-4113
US

IV. Provider business mailing address

11275 SPRINGFIELD PIKE
CINCINNATI OH
45246-4113
US

V. Phone/Fax

Practice location:
  • Phone: 513-984-1234
  • Fax: 513-686-1040
Mailing address:
  • Phone: 513-984-1234
  • Fax: 513-686-1040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1623
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number1623
License Number StateOH

VIII. Authorized Official

Name: MR. JOSHUA L HOWARD
Title or Position: DIRECTOR
Credential:
Phone: 513-686-1004