MEDICARE: CRADLE FOR YOUTH INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251300000X	Local Education Agency (LEA)
2	251B00000X	Case Management Agency
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center
4	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1508689308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRADLE FOR YOUTH INC.

Provider Business Mailing Address
First Line	:	5834 MONROE ST STE A
Second Line	:
City	:	SYLVANIA
State	:	OH
Zip	:	43560-2265
Country	:	US
Telephone Number	:	419-304-3937
Fax Number	:

Provider Business Practice Location Address
First Line	:	2053 N 14TH ST
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43620-1912
Country	:	US
Telephone Number	:	419-304-3937
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. VALERIE L POWELL
Credential	:	M.ED
Telephone Number	:	419-304-3937

Provider Enumeration Date	:	11/01/2024
Last Update Date	:	11/01/2024

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