Healthcare Provider Details

I. General information

NPI: 1396493185
Provider Name (Legal Business Name): KINDRED SPIRIT BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3618 W MARKET ST # E15
FAIRLAWN OH
44333-2425
US

IV. Provider business mailing address

PO BOX 4036
COPLEY OH
44321-0036
US

V. Phone/Fax

Practice location:
  • Phone: 234-466-0445
  • Fax:
Mailing address:
  • Phone: 330-271-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. TANIA S LODGE
Title or Position: CLINICAL DIRECTOR
Credential: PHD
Phone: 234-466-0445