Basic Information
| Provider Information | |||||||||
| NPI: | 1104337583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOOLEY | ||||||||
| FirstName: | HAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSSA, LISW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | NING | ||||||||
| OtherFirstName: | HAN | ||||||||
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| OtherCredential: | MSSA, LSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3484 W 125TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441113557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466459362 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3518 W 25TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441091951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167412241 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2017 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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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 | 1041C0700X | I.1901421 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0264395 | 05 | OH | MEDICAID |