=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528411097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RACING FOR RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2016
-----------------------------------------------------
Last Update Date | 08/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6202 TRUST DR
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43528-8425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-824-8462
-----------------------------------------------------
Fax | 419-517-0514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6202 TRUST DR
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43528-8425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-824-8462
-----------------------------------------------------
Fax | 419-517-0514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | TODD P CRANDELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-824-8462
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 1252124
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1252124
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------