MEDICARE: NATHANIEL HOLLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	175T00000X	Peer Specialist	01519	OH

General Provider Information

NPI Number	:	1174163331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHANIEL HOLLIS

Provider Business Mailing Address
First Line	:	1400 E 55TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44103-1304
Country	:	US
Telephone Number	:	216-848-5428
Fax Number	:

Provider Business Practice Location Address
First Line	:	9424 NELSON AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44105-4059
Country	:	US
Telephone Number	:	216-562-9767
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2020
Last Update Date	:	12/08/2020

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Directions to “ NATHANIEL HOLLIS ” Practice Location

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