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General NPI Number Information
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NPI Number | 1396423265
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Entity Type | Organization
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Legal Business Name | -
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Dates
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Enumeration Date | 07/10/2023
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Last Update Date | 07/10/2023
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Provider Practice Location Address
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Address Line | 1001 LAKESIDE AVE E STE 1350
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City | CLEVELAND
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State | OH
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Zip | 44114-1142
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Country | US
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Telephone | 216-490-8920
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Fax |
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Provider Business Mailing Address
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Address Line | 3885 E 186TH ST
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City | CLEVELAND
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State | OH
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Zip | 44122-6558
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Country | US
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Telephone | 216-971-2253
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. NICOLE ELISE WORTHEY
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Credential | B.A. CGS, OCPRS-MH-S
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Telephone | 216-971-2253
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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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 | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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