MEDICARE: MIDWEST MENTAL HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1053944090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST MENTAL HEALTH LLC

Provider Business Mailing Address
First Line	:	4086 BROADWAY
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-3025
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4086 BROADWAY
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-3025
Country	:	US
Telephone Number	:	740-804-1526
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	MICHELLE JOHNSON
Credential	:
Telephone Number	:	740-804-1526

Provider Enumeration Date	:	02/18/2020
Last Update Date	:	02/18/2020

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