Provider Demographics
NPI:1063074771
Name:SCIOTO FAMILY AND BEHAVIORAL MEDICINE
Entity type:Organization
Organization Name:SCIOTO FAMILY AND BEHAVIORAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAASTRUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-871-7379
Mailing Address - Street 1:5611 GALLIA ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5520
Mailing Address - Country:US
Mailing Address - Phone:740-529-0083
Mailing Address - Fax:
Practice Address - Street 1:4502 GALLIA ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-5541
Practice Address - Country:US
Practice Address - Phone:740-529-7020
Practice Address - Fax:740-529-7085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-02
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0332290Medicaid
OH0190824Medicaid
OH0359670Medicaid