=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366259376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATING MOVEMENT AND CHANGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2024
-----------------------------------------------------
Last Update Date | 12/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24500 CENTER RIDGE RD STE 130
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44145-5602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-288-3501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24500 CENTER RIDGE RD STE 130
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44145-5602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-288-3501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | MR. MATTHEW JOHN CORBETT
-----------------------------------------------------
Credential | LISW-S
-----------------------------------------------------
Telephone | 216-288-3501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------