Provider Demographics
NPI:1720599095
Name:PRIMM, MONIQUE ESTELLA (LSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:ESTELLA
Last Name:PRIMM
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22140 EUCLID AVE APT 401
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1614
Mailing Address - Country:US
Mailing Address - Phone:216-704-9123
Mailing Address - Fax:
Practice Address - Street 1:4600 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4371
Practice Address - Country:US
Practice Address - Phone:216-431-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1601173104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS.1601173Medicaid