Healthcare Provider Details

I. General information

NPI: 1184380867
Provider Name (Legal Business Name): FREEDOM YOUTH PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 EAST 174TH STREET
CLEVELAND OH
44110-2934
US

IV. Provider business mailing address

1421 EAST 174TH STREET
CLEVELAND OH
44110-2934
US

V. Phone/Fax

Practice location:
  • Phone: 216-230-2005
  • Fax:
Mailing address:
  • Phone: 216-230-2005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ZARELL ZACKITOUS PATTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 216-230-2005