=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669971222
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVELYN VEITH SOBCZAK LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2018
-----------------------------------------------------
Last Update Date | 03/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1744 PAYNE AVE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44114-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-623-6555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 575 CRESTVIEW DR
-----------------------------------------------------
City | BAY VILLAGE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44140-1727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-469-4271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | C005006
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C.0005066
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------