Healthcare Provider Details

I. General information

NPI: 1417625666
Provider Name (Legal Business Name): B. RILEY SOBER HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W 117TH ST
CLEVELAND OH
44111-1642
US

IV. Provider business mailing address

2121 W 117TH ST
CLEVELAND OH
44111-1642
US

V. Phone/Fax

Practice location:
  • Phone: 216-417-4831
  • Fax:
Mailing address:
  • Phone: 216-417-4831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. RAFAEL ANTONIO CORREA
Title or Position: FOUNDER
Credential:
Phone: 216-417-4831