Provider Demographics
NPI:1154835007
Name:CORREA, RAFAEL ANTONIO JR (LCDC III)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ANTONIO
Last Name:CORREA
Suffix:JR
Gender:M
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 1:2121 W 117TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-1642
Practice Address - Country:US
Practice Address - Phone:216-417-4831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162613101YA0400X
OH162598101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)