Healthcare Provider Details

I. General information

NPI: 1164782017
Provider Name (Legal Business Name): NOVA BEHAVIORAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 BECKMAN ST
DAYTON OH
45410-2165
US

IV. Provider business mailing address

732 BECKMAN ST
DAYTON OH
45410-2165
US

V. Phone/Fax

Practice location:
  • Phone: 937-253-1680
  • Fax: 937-253-8990
Mailing address:
  • Phone: 937-253-1680
  • Fax: 937-253-8990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number10-2063
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1407
License Number StateOH

VIII. Authorized Official

Name: MR. JOHN W GORIS
Title or Position: CEO
Credential: MS, LSW, LPCC-SC
Phone: 937-253-1680