=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598382723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCD & ANXIETY CENTER OF CLEVELAND LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2020
-----------------------------------------------------
Last Update Date | 07/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19220 LORAIN RD STE 203
-----------------------------------------------------
City | FAIRVIEW PARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44126-1976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-393-7749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19220 LORAIN RD STE 203
-----------------------------------------------------
City | FAIRVIEW PARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44126-1976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-393-7749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LLC MEMBER
-----------------------------------------------------
Name | DR. JONAH LAKIN
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 925-804-5532
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------