Healthcare Provider Details

I. General information

NPI: 1972248672
Provider Name (Legal Business Name): LAUREN DITTRICH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
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: 440-212-2579
  • Fax:
Mailing address:
  • Phone: 440-212-2579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162921
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: