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General NPI Number Information
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NPI Number | 1184380867
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Entity Type | Organization
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Legal Business Name | FREEDOM YOUTH PROGRAM
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Dates
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Enumeration Date | 11/16/2021
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Last Update Date | 04/19/2022
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Provider Practice Location Address
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Address Line | 1421 EAST 174TH STREET
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City | CLEVELAND
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State | OH
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Zip | 44110-2934
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Country | US
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Telephone | 216-230-2005
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Fax |
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Provider Business Mailing Address
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Address Line | 1421 EAST 174TH STREET
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City | CLEVELAND
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State | OH
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Zip | 44110-2934
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Country | US
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Telephone | 216-230-2005
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. ZARELL ZACKITOUS PATTON
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Credential |
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Telephone | 216-230-2005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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