Healthcare Provider Details

I. General information

NPI: 1225604804
Provider Name (Legal Business Name): SIERRA BREEZE SOUTHERN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SIERRA BREEZE SOUTHERN LPC

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 W MAIN ST STE 103
KENT OH
44240-2461
US

IV. Provider business mailing address

265 W MAIN ST STE 103
KENT OH
44240-2461
US

V. Phone/Fax

Practice location:
  • Phone: 216-839-2273
  • Fax: 216-896-0735
Mailing address:
  • Phone: 216-839-2273
  • Fax: 216-896-0735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2608566
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: