Provider Demographics
NPI:1669493540
Name:CLEVELAND PSYCHOSOCIAL SERVICE, INC.
Entity Type:Organization
Organization Name:CLEVELAND PSYCHOSOCIAL SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-482-3370
Mailing Address - Street 1:924 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3833
Mailing Address - Country:US
Mailing Address - Phone:704-482-3370
Mailing Address - Fax:704-482-3383
Practice Address - Street 1:809 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3978
Practice Address - Country:US
Practice Address - Phone:704-487-4422
Practice Address - Fax:704-487-4304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300640BMedicaid