Healthcare Provider Details

I. General information

NPI: 1073069563
Provider Name (Legal Business Name): LALESCIA LAVONE HURT PEER SUPPORT SPECIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8809 GRAND DIVISION AVE
CLEVELAND OH
44125-1349
US

IV. Provider business mailing address

8809 GRAND DIVISION AVE
CLEVELAND OH
44125-1349
US

V. Phone/Fax

Practice location:
  • Phone: 216-470-2998
  • Fax:
Mailing address:
  • Phone: 216-470-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: