=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942696083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOTUS HEART LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2015
-----------------------------------------------------
Last Update Date | 12/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24500 CENTER RIDGE RD
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44145-5601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-533-4966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26719 BRUCE RD
-----------------------------------------------------
City | BAY VILLAGE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44140-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MS. MARISSA LEE FERRER
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 216-533-4966
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | IO80073
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------