MEDICARE: CITIZENS LEADERSHIP ACADEMY

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	103TB0200X	Cognitive & Behavioral Psychologist
2	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1972944031
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITIZENS LEADERSHIP ACADEMY

Provider Business Mailing Address
First Line	:	9711 LAMONT AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-4124
Country	:	US
Telephone Number	:	216-456-2086
Fax Number	:	216-391-4770

Provider Business Practice Location Address
First Line	:	9711 LAMONT AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-4124
Country	:	US
Telephone Number	:	216-456-2086
Fax Number	:	216-391-4770

Authorized Official
Title or Position	:	CFO
Name	:	CHARLES DAANE
Credential	:
Telephone Number	:	216-456-2086

Provider Enumeration Date	:	07/17/2013
Last Update Date	:	09/06/2014

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