=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033909320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. ILYA YAROSLAVSKY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2025
-----------------------------------------------------
Last Update Date | 05/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3075 CORYDON RD
-----------------------------------------------------
City | CLEVELAND HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44118-3560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-877-8523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3075 CORYDON RD
-----------------------------------------------------
City | CLEVELAND HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44118-3560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 7492
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------