Basic Information
| Provider Information | |||||||||
| NPI: | 1295195857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEROCK | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LPCC-S, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3518 W 25TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441091951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308651841 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3518 W 25TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441091951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167412241 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2016 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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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 | LICDC.181814 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | E.1700423-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0250090 | 05 | OH | MEDICAID |