MEDICARE: OHIO FAMILY COUNSELING AND RECOVERY SERVICES, LLC

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	101YM0800X	Mental Health Counselor		OH

General Provider Information

NPI Number	:	1356831432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OHIO FAMILY COUNSELING AND RECOVERY SERVICES, LLC

Provider Business Mailing Address
First Line	:	17325 EUCLID AVE STE 4028
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-1270
Country	:	US
Telephone Number	:	803-565-9742
Fax Number	:

Provider Business Practice Location Address
First Line	:	17325 EUCLID AVE STE 3026
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-1255
Country	:	US
Telephone Number	:	803-565-9742
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF QUALITY ASSURANCE
Name	:	MR. DEMETRIUS HENDERSON
Credential	:
Telephone Number	:	803-565-9742

Provider Enumeration Date	:	05/15/2018
Last Update Date	:	06/17/2020

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