Basic Information
| Provider Information | |||||||||
| NPI: | 1083133896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PUDA | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30800 CHAGRIN BLVD. | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165910324 | ||||||||
| FaxNumber: | 2165911243 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 WINSLOW AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441132336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167810550 | ||||||||
| FaxNumber: | 2167711563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2017 | ||||||||
| LastUpdateDate: | 11/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.164576 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2374229 | 05 | OH | MEDICAID |