Healthcare Provider Details

I. General information

NPI: 1528559473
Provider Name (Legal Business Name): TAYLOR MATUSIK LCDC III
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2018
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 E 55TH ST
CLEVELAND OH
44103-3602
US

IV. Provider business mailing address

1804 E 55TH ST
CLEVELAND OH
44103-3602
US

V. Phone/Fax

Practice location:
  • Phone: 216-762-1237
  • Fax:
Mailing address:
  • Phone: 216-762-1237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number162450
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: