Healthcare Provider Details

I. General information

NPI: 1295324465
Provider Name (Legal Business Name): TRACEY CASSANDRA BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1359 E 65TH ST
CLEVELAND OH
44103-2541
US

IV. Provider business mailing address

10701 EAST BLVD
CLEVELAND OH
44106-1702
US

V. Phone/Fax

Practice location:
  • Phone: 216-272-7920
  • Fax:
Mailing address:
  • Phone: 216-272-7920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: