Healthcare Provider Details

I. General information

NPI: 1679958102
Provider Name (Legal Business Name): DAVID PINES JR. LCDCIII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14707 S CHESHIRE ST
BURTON OH
44021-9601
US

IV. Provider business mailing address

6900 RIDGE RD
PARMA OH
44129-5650
US

V. Phone/Fax

Practice location:
  • Phone: 440-887-1100
  • Fax: 440-887-1103
Mailing address:
  • Phone: 440-887-1100
  • Fax: 440-887-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.001719
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number141005
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: