Provider Demographics
NPI:1588219190
Name:CLEGG, COLIN JAMES (CDCA)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:JAMES
Last Name:CLEGG
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30800 CHAGRIN BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5925
Mailing Address - Country:US
Mailing Address - Phone:216-591-1253
Mailing Address - Fax:
Practice Address - Street 1:30800 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44124-5925
Practice Address - Country:US
Practice Address - Phone:216-591-1253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.171039101YA0400X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2864093Medicaid