MEDICARE: KAITLYN GENESIS CROSS

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	175T00000X	Peer Specialist		OH

General Provider Information

NPI Number	:	1982162400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN GENESIS CROSS

Provider Business Mailing Address
First Line	:	5554 SUNSET LN
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44134-2086
Country	:	US
Telephone Number	:	216-375-6670
Fax Number	:

Provider Business Practice Location Address
First Line	:	3637 GREEN RD STE 3G
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-5717
Country	:	US
Telephone Number	:	216-220-8774
Fax Number	:

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

Provider Enumeration Date	:	03/04/2019
Last Update Date	:	03/04/2019

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