Healthcare Provider Details

I. General information

NPI: 1457076127
Provider Name (Legal Business Name): CLINTON L GURLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13510 SHADY OAK BLVD
CLEVELAND OH
44125-6027
US

IV. Provider business mailing address

13510 SHADY OAK BLVD
CLEVELAND OH
44125-6027
US

V. Phone/Fax

Practice location:
  • Phone: 216-513-3922
  • Fax:
Mailing address:
  • Phone: 216-513-3922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: