Provider Demographics
NPI:1558801746
Name:A TRANSFORMING LIFE WELLNESS CTR LLC
Entity Type:Organization
Organization Name:A TRANSFORMING LIFE WELLNESS CTR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:216-702-8526
Mailing Address - Street 1:7085 W 130TH ST
Mailing Address - Street 2:#201A
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-7851
Mailing Address - Country:US
Mailing Address - Phone:440-565-7833
Mailing Address - Fax:440-684-9030
Practice Address - Street 1:781 BETA DR
Practice Address - Street 2:SUITE K1
Practice Address - City:MAYFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44143-2356
Practice Address - Country:US
Practice Address - Phone:440-565-7833
Practice Address - Fax:440-684-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0500069101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH896347Medicaid