Basic Information
| Provider Information | |||||||||
| NPI: | 1669771747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUDA | ||||||||
| FirstName: | J. CHRISTOPHER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CUDA | ||||||||
| OtherFirstName: | CHRIS | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1865 N RIDGE RD E STE D | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440553359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403410270 | ||||||||
| FaxNumber: | 4402770459 | ||||||||
| Practice Location | |||||||||
| Address1: | 1865 N RIDGE RD E STE D | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403410270 | ||||||||
| FaxNumber: | 4402770459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2011 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I0800293 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0210684 | 05 | OH | MEDICAID |