Healthcare Provider Details

I. General information

NPI: 1457736134
Provider Name (Legal Business Name): DOUGLAS C DEROBERTS LICDC II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5209 DETROIT AVE
CLEVELAND OH
44102-2224
US

IV. Provider business mailing address

5209 DETROIT AVE
CLEVELAND OH
44102-2224
US

V. Phone/Fax

Practice location:
  • Phone: 216-325-9123
  • Fax:
Mailing address:
  • Phone: 216-325-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number060103
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: