Provider Demographics
NPI:1588139125
Name:ELIJAH, ANTWON E I (QMHS/CMS)
Entity type:Individual
Prefix:MR
First Name:ANTWON
Middle Name:E
Last Name:ELIJAH
Suffix:I
Gender:M
Credentials:QMHS/CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S EDWIN C MOSES BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-734-8333
Mailing Address - Fax:
Practice Address - Street 1:5050 MADISON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-1491
Practice Address - Country:US
Practice Address - Phone:513-272-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
OHS.1800373-TRNE1041C0700X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical