=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386897189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LESBIAN, GAY, BISEXUAL & TRANSGENDER COMMUNITY CENTER OF GREATER CLEVE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2008
-----------------------------------------------------
Last Update Date | 10/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6600 DETROIT AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44102-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-651-5428
-----------------------------------------------------
Fax | 216-651-6439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6600 DETROIT AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44102-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-651-5428
-----------------------------------------------------
Fax | 216-651-6439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | SUSAN M DOERFER
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 216-651-5428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I0009423
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------