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General NPI Number Information
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NPI Number | 1558403451
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Entity Type | Organization
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Legal Business Name | RAVENWOOD MENTAL HEALTH CENTER
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Dates
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Enumeration Date | 02/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12557 RAVENWOOD DR
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City | CHARDON
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State | OH
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Zip | 44024-9009
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Country | US
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Telephone | 440-285-3568
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Fax |
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Provider Business Mailing Address
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Address Line | 118 GREENCLIFF DR
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City | BEDFORD
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State | OH
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Zip | 44146-3442
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Country | US
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Telephone | 216-587-5935
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH THERAPIST
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Name | MS. KORINNE GONGOS
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Credential | M.ED., LPC-TEMP
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Telephone | 440-285-3568
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | C.0500215.TEMP
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License Number State | OH
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