Provider Demographics
NPI:1760008155
Name:FARRELL, MATTHEW (LCDC, PRS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FARRELL
Suffix:
Gender:M
Credentials:LCDC, PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21270 LORAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2121
Mailing Address - Country:US
Mailing Address - Phone:440-672-1299
Mailing Address - Fax:
Practice Address - Street 1:21270 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2121
Practice Address - Country:US
Practice Address - Phone:440-672-1299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OHLCDCII.162006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist