Provider Demographics
NPI:1013319599
Name:NORTHEAST REINTEGRATION CENTER
Entity type:Organization
Organization Name:NORTHEAST REINTEGRATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTYKA
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:216-771-6460
Mailing Address - Street 1:2675 E 30TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-3000
Mailing Address - Country:US
Mailing Address - Phone:216-771-6460
Mailing Address - Fax:216-623-0992
Practice Address - Street 1:2675 E 30TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3000
Practice Address - Country:US
Practice Address - Phone:216-771-6460
Practice Address - Fax:216-623-0992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5787251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGTMOTYKAMedicaid