MEDICARE: GOODWILL GREATER CLEVELAND AND EAST CENTRAL OHIO

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	231H00000X	Audiologist	A00436	OH
2	235Z00000X	Speech-Language Pathologist	SP2281	OH
3	235Z00000X	Speech-Language Pathologist	SP8183	OH
4	235Z00000X	Speech-Language Pathologist	SP3189	OH
5	261QH0100X	Health Service Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	733018	OTHER	OH	BUCKEYE HEALTH PLAN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194943860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODWILL GREATER CLEVELAND AND EAST CENTRAL OHIO

Provider Business Mailing Address
First Line	:	408 NINTH STREET SW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44707
Country	:	US
Telephone Number	:	330-445-1059
Fax Number	:	330-454-1014

Provider Business Practice Location Address
First Line	:	408 NINTH STREET SW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44707-4714
Country	:	US
Telephone Number	:	330-445-1035
Fax Number	:	330-454-1014

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MARK TREW
Credential	:
Telephone Number	:	330-445-1035

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	12/02/2022

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Directions to “GOODWILL GREATER CLEVELAND AND EAST CENTRAL OHIO ” Practice Location

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