Provider Demographics
NPI:1104895176
Name:STATE OF OHIO DEPARTMENT OF MENTAL HEALTH
Entity type:Organization
Organization Name:STATE OF OHIO DEPARTMENT OF MENTAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FASONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-466-9930
Mailing Address - Street 1:30 E. BROAD ST
Mailing Address - Street 2:11TH FLOOR - FISCAL ADMINISTRATION
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3430
Mailing Address - Country:US
Mailing Address - Phone:614-466-6583
Mailing Address - Fax:614-644-5331
Practice Address - Street 1:157 W CEDAR ST
Practice Address - Street 2:SUITE B
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2564
Practice Address - Country:US
Practice Address - Phone:330-467-7131
Practice Address - Fax:330-467-2420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10408OtherMACSIS
OH2452804Medicaid
OH9321299Medicare PIN