Basic Information
Provider Information | |||||||||
NPI: | 1124322730 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRASS | ||||||||
FirstName: | ALICIA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPCC-S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1700 BEACONWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH EUCLID | ||||||||
State: | OH | ||||||||
PostalCode: | 441213728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2165708508 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 22001 FAIRMOUNT BLVD | ||||||||
Address2: |   | ||||||||
City: | SHAKER HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441184819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2169322800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/23/2010 | ||||||||
LastUpdateDate: | 02/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | E.0600612 SUPV | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.