Provider Demographics
NPI:1396423265
Name:-
Entity type:Organization
Organization Name:-
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:WORTHEY
Authorized Official - Suffix:
Authorized Official - Credentials:BA CGS, OCPRS-MH-S
Authorized Official - Phone:216-971-2253
Mailing Address - Street 1:3885 E 186TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44122-6558
Mailing Address - Country:US
Mailing Address - Phone:216-971-2253
Mailing Address - Fax:
Practice Address - Street 1:1001 LAKESIDE AVE E STE 1350
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-1142
Practice Address - Country:US
Practice Address - Phone:216-490-8920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRAIN SAFE SOLUTIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider Organization