=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487272225
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTHENTIC PRIDE THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2020
-----------------------------------------------------
Last Update Date | 07/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25201 CHAGRIN BLVD STE 390
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-5637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-400-5709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5782 ANDREWS RD APT I103
-----------------------------------------------------
City | MENTOR ON THE LAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-2659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-400-5709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MR. EMERSON LEE DOUGLAS
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 216-400-5709
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------