MEDICARE: CLINTONVILLE-BEECHWOLD COMMUNITY RESOURCES CENTER

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1144688805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINTONVILLE-BEECHWOLD COMMUNITY RESOURCES CENTER

Provider Business Mailing Address
First Line	:	3222 N HIGH ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43202-1114
Country	:	US
Telephone Number	:	614-268-3539
Fax Number	:	614-268-5028

Provider Business Practice Location Address
First Line	:	3222 N HIGH ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43202-1114
Country	:	US
Telephone Number	:	614-268-3539
Fax Number	:	614-268-5028

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. CHARLES WILLIAM OWENS
Credential	:	LISW-S, ACSW
Telephone Number	:	614-268-3539

Provider Enumeration Date	:	02/09/2016
Last Update Date	:	02/09/2016

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