Provider Demographics
NPI:1861623522
Name:ODONOGHUE, JOAN LESLIE (LICDC)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:LESLIE
Last Name:ODONOGHUE
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 PEARL RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3615
Mailing Address - Country:US
Mailing Address - Phone:440-816-8200
Mailing Address - Fax:440-816-8197
Practice Address - Street 1:7265 OLD OAK BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3342
Practice Address - Country:US
Practice Address - Phone:440-816-8200
Practice Address - Fax:440-816-8197
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH83976101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)