Healthcare Provider Details

I. General information

NPI: 1700534575
Provider Name (Legal Business Name): THIRD STREET COMMUNITY CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/11/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 PARK AVE W STE 200
ONTARIO OH
44906-1226
US

IV. Provider business mailing address

600 W 3RD ST
MANSFIELD OH
44906-2633
US

V. Phone/Fax

Practice location:
  • Phone: 419-525-6730
  • Fax:
Mailing address:
  • Phone: 419-522-6191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PEGGY ANDERSON
Title or Position: CEO
Credential:
Phone: 419-526-7880