Provider Demographics
NPI:1548974793
Name:SQUARE ONE GJM
Entity type:Organization
Organization Name:SQUARE ONE GJM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:JESSIE
Authorized Official - Last Name:HATEM
Authorized Official - Suffix:
Authorized Official - Credentials:S 1903372
Authorized Official - Phone:740-441-5809
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-0272
Mailing Address - Country:US
Mailing Address - Phone:740-441-5809
Mailing Address - Fax:740-578-9242
Practice Address - Street 1:49 OLIVE ST
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1632
Practice Address - Country:US
Practice Address - Phone:740-441-5809
Practice Address - Fax:740-578-9242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1447716352Medicaid