Healthcare Provider Details

I. General information

NPI: 1871029629
Provider Name (Legal Business Name): PROVIDENCE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 W 32ND ST
CLEVELAND OH
44113-4018
US

IV. Provider business mailing address

2050 W 32ND ST
CLEVELAND OH
44113-4018
US

V. Phone/Fax

Practice location:
  • Phone: 216-651-5982
  • Fax:
Mailing address:
  • Phone: 216-651-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOH

VIII. Authorized Official

Name: NATALIE LEEK
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 216-651-5982