Provider Demographics
NPI:1548764087
Name:DANIELS, LAURA DEVONNE (CDCA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:DEVONNE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3746 PROSPECT AVE E
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2706
Mailing Address - Country:US
Mailing Address - Phone:216-391-6672
Mailing Address - Fax:216-391-6433
Practice Address - Street 1:3746 PROSPECT AVE E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2706
Practice Address - Country:US
Practice Address - Phone:216-391-6672
Practice Address - Fax:216-391-6433
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00036175T00000X
OH121453101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-1836284Medicaid