MEDICARE: PROUD TO BE, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QP2300X	Primary Care Clinic/Center
3	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1376050542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROUD TO BE, INC

Provider Business Mailing Address
First Line	:	4812 LINDSEY LN
Second Line	:
City	:	RICHMOND HTS
State	:	OH
Zip	:	44143-2928
Country	:	US
Telephone Number	:	216-374-7682
Fax Number	:

Provider Business Practice Location Address
First Line	:	11811 SHAKER BLVD STE 123
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-1927
Country	:	US
Telephone Number	:	216-374-7682
Fax Number	:	216-455-5436

Authorized Official
Title or Position	:	CEO
Name	:	TIFFANY MARTIN THORNTON
Credential	:	NP
Telephone Number	:	216-374-7682

Provider Enumeration Date	:	01/09/2018
Last Update Date	:	03/15/2018

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Directions to “PROUD TO BE, INC ” Practice Location

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