Healthcare Provider Details

I. General information

NPI: 1093229957
Provider Name (Legal Business Name): ANNA IRIS LILLIE CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANNA IRIS KNOTH LCDCII

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 E 89TH ST
CLEVELAND OH
44106-2007
US

IV. Provider business mailing address

1909 E 89TH ST
CLEVELAND OH
44106-2007
US

V. Phone/Fax

Practice location:
  • Phone: 216-231-3772
  • Fax: 216-231-5040
Mailing address:
  • Phone: 216-231-3772
  • Fax: 216-231-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number140521
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: