Basic Information
| Provider Information | |||||||||
| NPI: | 1407928237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECTRUM OF SUPPORTIVE SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 DETROIT AVENUE | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441242710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169392065 | ||||||||
| FaxNumber: | 2169392077 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 DETROIT AVENUE | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441242710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169392065 | ||||||||
| FaxNumber: | 2169392077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MORSE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 2169392065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | JD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 0339 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 10232 | 01 | OH | DEPT OF MENTAL HEALTH | OTHER |