MEDICARE: SQUARE ONE COUNSELING AND PSYCHOTHERAPY

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	1041C0700X	Clinical Social Worker	I.1000021-SUPV	OH

General Provider Information

NPI Number	:	1801392238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SQUARE ONE COUNSELING AND PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	PO BOX 221261
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-0996
Country	:	US
Telephone Number	:	216-970-0732
Fax Number	:	216-274-9007

Provider Business Practice Location Address
First Line	:	2460 FAIRMOUNT BLVD STE 320
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44106-3164
Country	:	US
Telephone Number	:	216-970-0732
Fax Number	:	216-274-9007

Authorized Official
Title or Position	:	SOCIAL WORKER/OWNER
Name	:	CHAVA EMMA HARRIS
Credential	:	LISW-S
Telephone Number	:	216-970-0732

Provider Enumeration Date	:	04/04/2018
Last Update Date	:	04/04/2018

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