Provider Demographics
NPI:1508557190
Name:B. RILEY SOBER HOUSE
Entity Type:Organization
Organization Name:B. RILEY SOBER HOUSE
Other - Org Name:B. RILEY HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER/ EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:CORREA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-417-4831
Mailing Address - Street 1:2121 W 117TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-1642
Mailing Address - Country:US
Mailing Address - Phone:216-417-4831
Mailing Address - Fax:216-417-0040
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:216-417-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-16
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0454981Medicaid