Healthcare Provider Details

I. General information

NPI: 1629248893
Provider Name (Legal Business Name): CHAGRIN FAMILY THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 LAUREL RD
CHAGRIN FALLS OH
44022-3937
US

IV. Provider business mailing address

107 LAUREL RD
CHAGRIN FALLS OH
44022
US

V. Phone/Fax

Practice location:
  • Phone: 440-804-6627
  • Fax: 440-543-4974
Mailing address:
  • Phone: 440-804-6627
  • Fax: 440-543-4974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0600139
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberI0600139
License Number StateOH

VIII. Authorized Official

Name: ANTHONY MARRA
Title or Position: DIRECTOR
Credential: LISW-S
Phone: 440-804-6627