Basic Information
Provider Information | |||||||||
NPI: | 1205337565 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BELLEFAIRE JEWISH CHILDREN'S BUREAU | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 22001 FAIRMOUNT BLVD | ||||||||
Address2: |   | ||||||||
City: | SHAKER HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441184819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2163208222 | ||||||||
FaxNumber: | 2163208733 | ||||||||
Practice Location | |||||||||
Address1: | 807 E WASHINGTON ST STE 150 | ||||||||
Address2: |   | ||||||||
City: | MEDINA | ||||||||
State: | OH | ||||||||
PostalCode: | 442563339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3302414444 | ||||||||
FaxNumber: | 3307210013 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2018 | ||||||||
LastUpdateDate: | 02/22/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | LEIGH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
AuthorizedOfficialTelephone: | 2163208222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 2447 | OH | N |   | Agencies | Community/Behavioral Health |   | 251S00000X | 01-0009 | OH | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 2864226 | 05 | OH |   | MEDICAID | 2847183 | 05 | OH |   | MEDICAID |