Healthcare Provider Details

I. General information

NPI: 1104567577
Provider Name (Legal Business Name): TASC OF SOUTHEAST OHIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 JACKSON PIKE
GALLIPOLIS OH
45631-1398
US

IV. Provider business mailing address

PO BOX 88
GALLIPOLIS OH
45631-0088
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-6471
  • Fax:
Mailing address:
  • Phone: 740-446-6471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CARRIE BURRIS
Title or Position: FISCAL MANAGER
Credential:
Phone: 740-446-6471