MEDICARE: TALESSIA LATAINA MARTIN CDCA PEER SUPPORT

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	175T00000X	Peer Specialist	APS.005740	OH

General Provider Information

NPI Number	:	1578387577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TALESSIA LATAINA MARTIN CDCA PEER SUPPORT

Provider Business Mailing Address
First Line	:	3033 PROJECT AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-3028
Country	:	US
Telephone Number	:	216-262-6150
Fax Number	:

Provider Business Practice Location Address
First Line	:	3033 PROJECT AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-3028
Country	:	US
Telephone Number	:	216-262-6150
Fax Number	:

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

Provider Enumeration Date	:	11/14/2024
Last Update Date	:	11/14/2024

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