Healthcare Provider Details

I. General information

NPI: 1437724937
Provider Name (Legal Business Name): SAMANTHA WAGONER QMHS3YRS CMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CARNEGIE AVE
CLEVELAND OH
44115-2641
US

IV. Provider business mailing address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

V. Phone/Fax

Practice location:
  • Phone: 440-260-8300
  • Fax:
Mailing address:
  • Phone: 216-320-8932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2207212
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: