Provider Demographics
NPI:1063008670
Name:CHARISSE ALI, LLC A LASTING IMPRESSION
Entity Type:Organization
Organization Name:CHARISSE ALI, LLC A LASTING IMPRESSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARISSE
Authorized Official - Middle Name:LILLIAN
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-319-2078
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44005-0548
Mailing Address - Country:US
Mailing Address - Phone:440-319-2078
Mailing Address - Fax:440-998-5820
Practice Address - Street 1:1440 W PROSPECT RD
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6668
Practice Address - Country:US
Practice Address - Phone:440-319-2078
Practice Address - Fax:440-998-5820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities