Healthcare Provider Details

I. General information

NPI: 1942235395
Provider Name (Legal Business Name): MARY H. RIVERA-BRAHM LSW, LICDC-S LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ROBERTS LSW, LICDC-S LCPC

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 MAPLE AVE
BEREA OH
44017-1227
US

IV. Provider business mailing address

454 MAPLE AVE
BEREA OH
44017-1227
US

V. Phone/Fax

Practice location:
  • Phone: 440-409-8507
  • Fax:
Mailing address:
  • Phone: 440-409-8507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number965683
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS-0021092
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180006589
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: