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Provider Information for 1619395910


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ERICA INNOCENT


Sex: Female

NPI: 1619395910
Last Updated: 2014-04-03
Certification Date:

Details

NameValue
NPI1619395910
Enumeration Date2014-04-03
NPI TypeNPI-1 Individual
Sole ProprietorYES
StatusActive
Mailing Address 3737 LANDER RD
CLEVELAND, OH 44124-5712
United States

Phone: | Fax:
 
Primary Practice Address 11801 BUCKEYE
CLEVELAND, OH 44120
United States

Phone: 216-831-2255 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDOH2871101
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 1041C0700X - Social Worker - ClinicalOH1430088