Provider Demographics
NPI:1992302384
Name:INDEPENDENT COMMUNITY SERVICES
Entity type:Organization
Organization Name:INDEPENDENT COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:JANAY
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-316-0557
Mailing Address - Street 1:675 DEIS DR # 201
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-8136
Mailing Address - Country:US
Mailing Address - Phone:513-817-4888
Mailing Address - Fax:
Practice Address - Street 1:675 DEIS DR # 201
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-8136
Practice Address - Country:US
Practice Address - Phone:513-817-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1902322027Medicaid