Provider Demographics
NPI:1447346564
Name:SOURCEONE GROUP INC
Entity type:Organization
Organization Name:SOURCEONE GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUCHWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:330-345-0955
Mailing Address - Street 1:210 E MILLTOWN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-1246
Mailing Address - Country:US
Mailing Address - Phone:330-345-0955
Mailing Address - Fax:330-345-3420
Practice Address - Street 1:210 E MILLTOWN RD
Practice Address - Street 2:SUITE B
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-1246
Practice Address - Country:US
Practice Address - Phone:330-345-0955
Practice Address - Fax:330-345-3420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9309291Medicare PIN