Basic Information
Provider Information | |||||||||
NPI: | 1962990127 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALING PATHWAYS CLEVELAND, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30701 LORAIN RD STE A | ||||||||
Address2: |   | ||||||||
City: | NORTH OLMSTED | ||||||||
State: | OH | ||||||||
PostalCode: | 440706325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4402745000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 20575 CENTER RIDGE RD STE 318 | ||||||||
Address2: |   | ||||||||
City: | ROCKY RIVER | ||||||||
State: | OH | ||||||||
PostalCode: | 441163422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2165631661 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2018 | ||||||||
LastUpdateDate: | 06/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CAPPETTO | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/ THERAPIST | ||||||||
AuthorizedOfficialTelephone: | 2165631661 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MAED, IMFT, LPCC-S | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 0334674 | 05 | OH |   | MEDICAID |