=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013319599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST REINTEGRATION CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2014
-----------------------------------------------------
Last Update Date | 09/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2675 E 30TH ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-771-6460
-----------------------------------------------------
Fax | 216-623-0992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2675 E 30TH ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-771-6460
-----------------------------------------------------
Fax | 216-623-0992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. GRACE MOTYKA
-----------------------------------------------------
Credential | PH. D.
-----------------------------------------------------
Telephone | 216-771-6460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 5787
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------