Healthcare Provider Details

I. General information

NPI: 1740745215
Provider Name (Legal Business Name): LIFE RENEWAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11116 TUSCORA AVE
CLEVELAND OH
44108-3054
US

IV. Provider business mailing address

11116 TUSCORA AVE
CLEVELAND OH
44108-3054
US

V. Phone/Fax

Practice location:
  • Phone: 216-835-3927
  • Fax:
Mailing address:
  • Phone: 216-835-3927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SYLVIA A REEVES
Title or Position: ADMIN
Credential:
Phone: 216-835-3927