Healthcare Provider Details

I. General information

NPI: 1871369579
Provider Name (Legal Business Name): TREE OF LIFE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 W BAGLEY RD STE 215
BEREA OH
44017-1312
US

IV. Provider business mailing address

34760 CENTER RIDGE RD UNIT 39533
NORTH RIDGEVILLE OH
44039-4722
US

V. Phone/Fax

Practice location:
  • Phone: 216-282-4749
  • Fax:
Mailing address:
  • Phone: 216-282-4749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TRACY DAWN
Title or Position: DIRECTOR
Credential: LISW
Phone: 216-282-4749