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General NPI Number Information
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NPI Number | 1407820343
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Entity Type | Organization
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Legal Business Name | YORK AVENUE CHURCH OF GOD TREATMENT CENTER
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Dates
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Enumeration Date | 02/16/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1228 W MARKET ST
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City | WARREN
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State | OH
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Zip | 44485-2780
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Country | US
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Telephone | 330-392-4199
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Fax | 330-392-4904
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Provider Business Mailing Address
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Address Line | 1228 W MARKET ST
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City | WARREN
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State | OH
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Zip | 44485-2780
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Country | US
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Telephone | 330-392-4199
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Fax | 330-392-4904
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. JOHNNY GRAHAM
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Credential | LICDC
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Telephone | 330-392-4199
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 6949
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License Number State | OH
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