Healthcare Provider Details

I. General information

NPI: 1326305582
Provider Name (Legal Business Name): LAKE-GEAUGA RECOVERY CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9083 MENTOR AVE
MENTOR OH
44060-6462
US

IV. Provider business mailing address

9083 MENTOR AVE
MENTOR OH
44060-6462
US

V. Phone/Fax

Practice location:
  • Phone: 440-255-0678
  • Fax: 440-255-6348
Mailing address:
  • Phone: 440-255-0678
  • Fax: 440-255-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. MELANIE BLASKO
Title or Position: PRESIDENT & CEO
Credential:
Phone: 440-205-2674