Provider Demographics
NPI:1902075955
Name:CRISIS INTERVENTION AND RECOVERY CENTER, INC.
Entity Type:Organization
Organization Name:CRISIS INTERVENTION AND RECOVERY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JESIOLOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:330-452-9812
Mailing Address - Street 1:832 MCKINLEY AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44703-2463
Mailing Address - Country:US
Mailing Address - Phone:330-452-9812
Mailing Address - Fax:
Practice Address - Street 1:832 MCKINLEY AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44703-2463
Practice Address - Country:US
Practice Address - Phone:330-452-9812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0203251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH430700Medicaid
OH2480864Medicaid
OH2480864Medicaid
OH9245161Medicare PIN