=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598010233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OHIOGUIDESTONE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2012
-----------------------------------------------------
Last Update Date | 08/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 CARNEGIE AVENUE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-2651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-234-2006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 434 EASTLAND RD.
-----------------------------------------------------
City | BEREA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44017-2058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-260-8327
-----------------------------------------------------
Fax | 440-234-8319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DONNA KEEGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 440-260-8300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | S21115
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------