Basic Information
| Provider Information | |||||||||
| NPI: | 1922508159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANEY | ||||||||
| FirstName: | MICKIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13701 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | EAST CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441123109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162241261 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 METROHEALTH DR | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441091900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167787800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2018 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | I.1801289 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.