=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891374930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON BEHAVIORAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2021
-----------------------------------------------------
Last Update Date | 04/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 N WOOD ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-201-2048
-----------------------------------------------------
Fax | 567-280-4395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 N WOOD ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-201-2048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. MELISSA ANN TESTER
-----------------------------------------------------
Credential | LICDC-CS, LSW
-----------------------------------------------------
Telephone | 567-201-2048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------