Provider Demographics
NPI:1376050542
Name:PROUD TO BE, INC
Entity Type:Organization
Organization Name:PROUD TO BE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:216-374-7682
Mailing Address - Street 1:4812 LINDSEY LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-2928
Mailing Address - Country:US
Mailing Address - Phone:216-374-7682
Mailing Address - Fax:
Practice Address - Street 1:11811 SHAKER BLVD STE 123
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-1927
Practice Address - Country:US
Practice Address - Phone:216-374-7682
Practice Address - Fax:216-455-5436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care