Healthcare Provider Details

I. General information

NPI: 1952891665
Provider Name (Legal Business Name): IDAMARI GEHALO MSW LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13422 KINSMAN RD
CLEVELAND OH
44120-4410
US

IV. Provider business mailing address

1535 WARREN RD UPPR UNIT
LAKEWOOD OH
44107-4064
US

V. Phone/Fax

Practice location:
  • Phone: 216-283-4400
  • Fax:
Mailing address:
  • Phone: 216-501-9552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2506996
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: