=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356140750
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE JOESPH KRAVETZ CDCA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2025
-----------------------------------------------------
Last Update Date | 03/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4705 STATE RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44109-5244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-468-6550
-----------------------------------------------------
Fax | 440-848-8894
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1980 BROOKPARK RD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44109-5810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-396-4565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | CDCA.191617
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CDCA.191617
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------