MEDICARE: TEEN START PROGRAM

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1801227863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEEN START PROGRAM

Provider Business Mailing Address
First Line	:	11580 CHEYENNE TRL APT G
Second Line	:
City	:	PARMA HEIGHTS
State	:	OH
Zip	:	44130-1991
Country	:	US
Telephone Number	:	877-263-7711
Fax Number	:

Provider Business Practice Location Address
First Line	:	3435 E 76TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44127-2016
Country	:	US
Telephone Number	:	877-263-7711
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. STANYA GREATHOUSE
Credential	:
Telephone Number	:	877-263-7711

Provider Enumeration Date	:	12/02/2013
Last Update Date	:	11/18/2016

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Directions to “TEEN START PROGRAM ” Practice Location

Language	Start Address	Practice Location

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