Healthcare Provider Details

I. General information

NPI: 1245290436
Provider Name (Legal Business Name): MARYHAVEN INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1791 ALUM CREEK DR
COLUMBUS OH
43207-1708
US

IV. Provider business mailing address

1791 ALUM CREEK DR
COLUMBUS OH
43207-1708
US

V. Phone/Fax

Practice location:
  • Phone: 614-324-5402
  • Fax: 614-827-8380
Mailing address:
  • Phone: 614-324-5402
  • Fax: 614-827-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1183
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1183
License Number StateOH

VIII. Authorized Official

Name: MR. GREGORY MICHAEL RITTER
Title or Position: BILLING/MEDICAL RECORDS ADMINISTRAT
Credential: LPCC, LICDC-CS
Phone: 614-324-5402