Provider Demographics
NPI:1710228614
Name:CLEVELAND FAMILY THERAPY LLC
Entity Type:Organization
Organization Name:CLEVELAND FAMILY THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:COAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCDCIII,PC
Authorized Official - Phone:440-210-4763
Mailing Address - Street 1:23360 CHAGRIN BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5537
Mailing Address - Country:US
Mailing Address - Phone:440-210-4763
Mailing Address - Fax:
Practice Address - Street 1:23360 CHAGRIN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5537
Practice Address - Country:US
Practice Address - Phone:440-210-4763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-03
Last Update Date:2013-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021164101YA0400X
OHC0501110101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12329204Medicaid