=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518090380
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK L. PRESTRIDGE I.M.F.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3235 PROSPECT AVE E
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-406-9217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 364 HIGH ST
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-1844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-715-2913
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | F.0000010
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------