=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033477906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRISIS INTERVENTION AND RECOVERY CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2012
-----------------------------------------------------
Last Update Date | 04/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 832 MCKINLEY AVE NW
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44703-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-452-9812
-----------------------------------------------------
Fax | 330-430-1288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 832 MCKINLEY AVE NW
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44703-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. BERNARD JESIOLOWSKI
-----------------------------------------------------
Credential | PHD.
-----------------------------------------------------
Telephone | 330-452-9812
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 0203
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------