MEDICARE: KESHA DENAY BACCUS

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	171M00000X	Case Manager/Care Coordinator
2	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1730727686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KESHA DENAY BACCUS

Provider Business Mailing Address
First Line	:	18414 GLEN AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-2811
Country	:	US
Telephone Number	:	216-417-9034
Fax Number	:

Provider Business Practice Location Address
First Line	:	2490 LEE BLVD
Second Line	:
City	:	CLEVELAND HTS
State	:	OH
Zip	:	44118-1268
Country	:	US
Telephone Number	:	216-600-5194
Fax Number	:

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

Provider Enumeration Date	:	12/11/2019
Last Update Date	:	11/10/2022

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Directions to “ KESHA DENAY BACCUS ” Practice Location

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