Provider Demographics
NPI:1265999791
Name:DANIELS, ROY ERIC (CDCA)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:ERIC
Last Name:DANIELS
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25551 N LAKELAND BLVD APT 102A
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-2426
Mailing Address - Country:US
Mailing Address - Phone:216-624-0156
Mailing Address - Fax:
Practice Address - Street 1:1400 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-1304
Practice Address - Country:US
Practice Address - Phone:216-391-6672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000941175T00000X
OH168716101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0335963Medicaid