Healthcare Provider Details

I. General information

NPI: 1396423265
Provider Name (Legal Business Name): -
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LAKESIDE AVE E STE 1350
CLEVELAND OH
44114-1142
US

IV. Provider business mailing address

3885 E 186TH ST
CLEVELAND OH
44122-6558
US

V. Phone/Fax

Practice location:
  • Phone: 216-490-8920
  • Fax:
Mailing address:
  • Phone: 216-971-2253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. NICOLE ELISE WORTHEY
Title or Position: OWNER
Credential: B.A. CGS, OCPRS-MH-S
Phone: 216-971-2253