MEDICARE: EVELYN LYNETTE BAILEY BA,SWA,LCDCIII

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	130328	OH
2	104100000X	Social Worker	1500019	OH

General Provider Information

NPI Number	:	1811403801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVELYN LYNETTE BAILEY BA,SWA,LCDCIII

Provider Business Mailing Address
First Line	:	4600 CARNEGIE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44103-4371
Country	:	US
Telephone Number	:	216-440-0051
Fax Number	:

Provider Business Practice Location Address
First Line	:	JORDAN COMMUNITY RESIDENTIAL CENTER
Second Line	:	2231 NORTH TAYLOR RD
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44112
Country	:	US
Telephone Number	:	216-441-2496
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2017
Last Update Date	:	07/24/2020

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