Provider Demographics
NPI:1053345975
Name:RAVENWOOD MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:RAVENWOOD MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC-S
Authorized Official - Phone:440-285-2170
Mailing Address - Street 1:12557 RAVENWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024
Mailing Address - Country:US
Mailing Address - Phone:440-285-2170
Mailing Address - Fax:440-285-2207
Practice Address - Street 1:12557 RAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024
Practice Address - Country:US
Practice Address - Phone:440-285-3568
Practice Address - Fax:440-285-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
OH261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0576916Medicaid
OH9190803Medicare UPIN