Provider Demographics
NPI:1235520602
Name:SMITH, JOHN JOSEPH
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 WOOSTER RD
Mailing Address - Street 2:SUITE 54
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-2674
Mailing Address - Country:US
Mailing Address - Phone:216-407-0437
Mailing Address - Fax:216-862-5143
Practice Address - Street 1:17400 NORTHWOOD AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-2210
Practice Address - Country:US
Practice Address - Phone:216-403-8640
Practice Address - Fax:216-862-1243
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1714764Medicaid