Basic Information
| Provider Information | |||||||||
| NPI: | 1790337889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISIAKIEWICZ | ||||||||
| FirstName: | KEVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22001 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169322800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16530 COMMERCE CT | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441306316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409895900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2019 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 167782 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | S.2207483 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | LICDC.162187 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.