Healthcare Provider Details

I. General information

NPI: 1235742685
Provider Name (Legal Business Name): PANACEA BEHAVIOR THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 MAHONING AVE STE 103
YOUNGSTOWN OH
44509-2337
US

IV. Provider business mailing address

2703 MAHONING AVE STE 103
YOUNGSTOWN OH
44509-2337
US

V. Phone/Fax

Practice location:
  • Phone: 330-980-2353
  • Fax: 330-781-5178
Mailing address:
  • Phone: 330-980-2353
  • Fax: 330-781-5178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: FAITH PALMER
Title or Position: OWNER
Credential: CDCA
Phone: 330-980-2353