Healthcare Provider Details

I. General information

NPI: 1629002951
Provider Name (Legal Business Name): ETHAN R BENORE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MLK JR DR
CLEVELAND OH
44104-3815
US

IV. Provider business mailing address

2801 MLK JR DR
CLEVELAND OH
44104-3815
US

V. Phone/Fax

Practice location:
  • Phone: 216-448-6253
  • Fax:
Mailing address:
  • Phone: 216-448-6253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6154
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6154
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: