Healthcare Provider Details

I. General information

NPI: 1093307654
Provider Name (Legal Business Name): CROSSROADS HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9220 MENTOR AVE
MENTOR OH
44060-6412
US

IV. Provider business mailing address

8445 MUNSON RD
MENTOR OH
44060-2410
US

V. Phone/Fax

Practice location:
  • Phone: 440-354-9924
  • Fax: 877-242-9583
Mailing address:
  • Phone: 440-255-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALICE IDEN
Title or Position: COO
Credential:
Phone: 440-255-1700