Healthcare Provider Details

I. General information

NPI: 1164924163
Provider Name (Legal Business Name): MR. SAMUEL VACHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 03/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 LORAIN AVE
CLEVELAND OH
44111-5428
US

IV. Provider business mailing address

11401 LORAIN AVE
CLEVELAND OH
44111-5428
US

V. Phone/Fax

Practice location:
  • Phone: 216-416-4277
  • Fax: 216-416-4273
Mailing address:
  • Phone: 216-416-4277
  • Fax: 216-416-4273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS.1303568
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: