Provider Demographics
NPI:1366526782
Name:HARBOR
Entity type:Organization
Organization Name:HARBOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-343-0947
Mailing Address - Street 1:3909 WOODLEY RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3909 WOODLEY RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1169
Practice Address - Country:US
Practice Address - Phone:419-725-3330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YP2500X, 103G00000X, 103TC0700X, 103TC1900X, 104100000X, 1041C0700X, 106H00000X, 207Q00000X, 2080P0006X, 2084P0800X, 2084P0804X, 2084P0805X
OH240261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01927OtherPARAMOUNT HEALTH CARE
110754-000OtherMAGELLAN
611706700OtherDOL FECA
060172OtherVALUE OPTIONS
OH2341639Medicaid
OH3126Medicaid
611706700OtherDOL FECA