MEDICARE: THE CONNECTED COUNSELOR

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

General Provider Information

NPI Number	:	1902513690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CONNECTED COUNSELOR

Provider Business Mailing Address
First Line	:	2189 PROFESSOR AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44113-3634
Country	:	US
Telephone Number	:	216-505-0959
Fax Number	:

Provider Business Practice Location Address
First Line	:	2189 PROFESSOR AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44113-3634
Country	:	US
Telephone Number	:	216-505-0959
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED AGENT
Name	:	MR. CARL POYTHRESS
Credential	:	NA
Telephone Number	:	216-645-2746

Provider Enumeration Date	:	11/01/2022
Last Update Date	:	03/23/2023

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