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5 Severance Cir Ste 802 Cleveland Heights OH 44118-1592 | |
| (216) 399-3130 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 5 Severance Cir Ste 802, Cleveland Heights, Ohio |
| Authorized Official Name and Position | Otimbum L Wilson (OWNER/ CLINICAL DIRECTOR) |
| Authorized Official Contact | 2163993130 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1924 Revere Rd Cleveland Heights OH 44118-2234 Ph: (952) 807-6093 | 5 Severance Cir Ste 802 Cleveland Heights OH 44118-1592 Ph: (216) 399-3130 |
| NPI Number | 1609460880 |
|---|---|
| Provider Enumeration Date | 02/27/2021 |
| Last Update Date | 11/09/2022 |
| Certification Date | 11/09/2022 |
| Medicare PECOS PAC ID | 8426425026 |
|---|---|
| Medicare Enrollment ID | O20221111000595 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1609460880 | NPI | - | NPPES |
| Provider Name | Jazmine Renay Danner |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1245769421 PECOS PAC ID: 0244632412 Enrollment ID: I20210709002093 |
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