Provider Demographics
NPI:1629248893
Name:CHAGRIN FAMILY THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:CHAGRIN FAMILY THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRA
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:440-804-6627
Mailing Address - Street 1:107 LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022
Mailing Address - Country:US
Mailing Address - Phone:440-804-6627
Mailing Address - Fax:440-543-4974
Practice Address - Street 1:107 LAUREL RD
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-3937
Practice Address - Country:US
Practice Address - Phone:440-804-6627
Practice Address - Fax:440-543-4974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI06001391041C0700X, 251S00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11814584OtherCAQH