Provider Demographics
NPI:1699355966
Name:AL-SHAMI, CONNIE (OCPRS)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:AL-SHAMI
Suffix:
Gender:F
Credentials:OCPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3559 E 153RD ST # UP
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-4907
Mailing Address - Country:US
Mailing Address - Phone:216-699-4115
Mailing Address - Fax:
Practice Address - Street 1:25201 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5600
Practice Address - Country:US
Practice Address - Phone:216-910-9015
Practice Address - Fax:216-910-9015
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002339175T00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty