Provider Demographics
NPI:1104567577
Name:TASC OF SOUTHEAST OHIO
Entity type:Organization
Organization Name:TASC OF SOUTHEAST OHIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-446-6471
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-0088
Mailing Address - Country:US
Mailing Address - Phone:740-446-6471
Mailing Address - Fax:
Practice Address - Street 1:499 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1398
Practice Address - Country:US
Practice Address - Phone:740-446-6471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH065834Medicaid