MEDICARE: MOUNDBUILDERS GUIDANCE CENTER, INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	0200008	OTHER	OH	MEDICARE CROSSOVER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2485734	OTHER	OH	RISPERDAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598723728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNDBUILDERS GUIDANCE CENTER, INC.

Provider Business Mailing Address
First Line	:	8402 BLACKJACK ROAD EXT
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-9193
Country	:	US
Telephone Number	:	740-397-0442
Fax Number	:	740-392-1814

Provider Business Practice Location Address
First Line	:	8402 BLACKJACK ROAD EXT
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-9193
Country	:	US
Telephone Number	:	740-397-0442
Fax Number	:	740-392-1814

Authorized Official
Title or Position	:	CEO
Name	:	MR. PATRICK C EVANS
Credential	:
Telephone Number	:	740-788-3400

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	05/09/2008

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Directions to “MOUNDBUILDERS GUIDANCE CENTER, INC. ” Practice Location

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