Provider Demographics
NPI:1144825969
Name:CUYAHOGA COUNTY BOARD OF DEVELOPMENTAL DISABILITIES
Entity type:Organization
Organization Name:CUYAHOGA COUNTY BOARD OF DEVELOPMENTAL DISABILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-736-2731
Mailing Address - Street 1:1275 LAKESIDE AVE., E.
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114
Mailing Address - Country:US
Mailing Address - Phone:216-241-8230
Mailing Address - Fax:216-861-0253
Practice Address - Street 1:1275 LAKESIDE AVE., E.
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114
Practice Address - Country:US
Practice Address - Phone:216-241-8230
Practice Address - Fax:216-861-0253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1800019Medicaid