Provider Demographics
NPI:1588824064
Name:IL-CAO FAMILY GUIDANCE CENTER
Entity type:Organization
Organization Name:IL-CAO FAMILY GUIDANCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WATSON-GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-532-7855
Mailing Address - Street 1:1518 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2140
Mailing Address - Country:US
Mailing Address - Phone:740-532-7855
Mailing Address - Fax:740-532-0557
Practice Address - Street 1:1518 S 3RD ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2140
Practice Address - Country:US
Practice Address - Phone:740-532-7855
Practice Address - Fax:740-532-0557
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IRONTON LAWRENCE COUNTY CAO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 074290251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1770549834Medicaid