Provider Demographics
NPI:1871029629
Name:PROVIDENCE HOUSE
Entity Type:Organization
Organization Name:PROVIDENCE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-651-5982
Mailing Address - Street 1:2050 W 32ND ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-4018
Mailing Address - Country:US
Mailing Address - Phone:216-651-5982
Mailing Address - Fax:
Practice Address - Street 1:2050 W 32ND ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-4018
Practice Address - Country:US
Practice Address - Phone:216-651-5982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251S00000X
251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No251S00000XAgenciesCommunity/Behavioral Health