Provider Demographics
NPI:1497527154
Name:KNOWLTON, CONSTANCE LAVERNE (CDCA, PRS)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:LAVERNE
Last Name:KNOWLTON
Suffix:
Gender:F
Credentials:CDCA, PRS
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:KNOWLTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CDCA,PRS
Mailing Address - Street 1:1444 E 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1318
Mailing Address - Country:US
Mailing Address - Phone:216-421-4956
Mailing Address - Fax:
Practice Address - Street 1:1444 E 111TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1318
Practice Address - Country:US
Practice Address - Phone:216-421-4956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.004527106S00000X
OH184286101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty