Healthcare Provider Details

I. General information

NPI: 1649230129
Provider Name (Legal Business Name): CHILDREN'S COMMUNITY ACCESS PROGRAM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 EUCLID AVE SUITE 204
CLEVELAND OH
44103-3749
US

IV. Provider business mailing address

5000 EUCLID AVE SUITE 204
CLEVELAND OH
44103-3749
US

V. Phone/Fax

Practice location:
  • Phone: 216-361-0633
  • Fax: 216-361-0644
Mailing address:
  • Phone: 216-361-0633
  • Fax: 216-361-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0562
License Number StateOH

VIII. Authorized Official

Name: MRS. SHERRY LYNN GIBSON
Title or Position: CHIEF OPERATING OFFICER
Credential: LSW, MSW
Phone: 216-361-0633