Healthcare Provider Details

I. General information

NPI: 1417864877
Provider Name (Legal Business Name): BEACON MENTAL HEALTH ASSOCIATES OF VAN WERT L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 EUCLID AVE STE 8196798
CLEVELAND OH
44114-3306
US

IV. Provider business mailing address

850 EUCLID AVE STE 8196798
CLEVELAND OH
44114-3306
US

V. Phone/Fax

Practice location:
  • Phone: 419-362-5597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THOMAS RUSSELL
Title or Position: CEO
Credential: DNP, CNP, FNP, PMHNP
Phone: 419-406-0067