=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508557190
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B. RILEY SOBER HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2023
-----------------------------------------------------
Last Update Date | 09/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 W 117TH ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44111-1642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-417-4831
-----------------------------------------------------
Fax | 216-417-0040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 W 117TH ST
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44111-1642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-417-4831
-----------------------------------------------------
Fax | 216-417-0040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/ EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | RAFAEL ANTONIO CORREA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-417-4831
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------