Provider Demographics
NPI:1124592894
Name:B. RILEY SOBER HOUSE
Entity Type:Organization
Organization Name:B. RILEY SOBER HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPCC, LICDC
Authorized Official - Phone:216-444-1195
Mailing Address - Street 1:3719 DENISON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-2691
Mailing Address - Country:US
Mailing Address - Phone:216-417-4831
Mailing Address - Fax:
Practice Address - Street 1:3719 DENISON AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-2691
Practice Address - Country:US
Practice Address - Phone:216-417-4831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1154835007Medicaid