Healthcare Provider Details

I. General information

NPI: 1871087296
Provider Name (Legal Business Name): MARISA D RODGERS QMHS BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 MIDWAY BLVD STE 210
ELYRIA OH
44035-2496
US

IV. Provider business mailing address

347 MIDWAY BLVD STE 210
ELYRIA OH
44035-2496
US

V. Phone/Fax

Practice location:
  • Phone: 440-324-5555
  • Fax:
Mailing address:
  • Phone: 440-324-5555
  • Fax: 440-324-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162395
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: