Provider Demographics
NPI:1104165521
Name:EDU-AT-TECH, LLC
Entity type:Organization
Organization Name:EDU-AT-TECH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ARIES
Authorized Official - Middle Name:NICHELLE
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:216-217-0561
Mailing Address - Street 1:PO BOX 91666
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-3666
Mailing Address - Country:US
Mailing Address - Phone:216-217-0561
Mailing Address - Fax:216-848-1202
Practice Address - Street 1:7102 WAKEFIELD AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-2972
Practice Address - Country:US
Practice Address - Phone:216-217-0561
Practice Address - Fax:216-848-1202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDU-AT-TECH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP8177231H00000X, 235Z00000X
OHMBE-20799231HA2400X, 231HA2500X, 235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology PractitionerGroup - Multi-Specialty
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology SupplierGroup - Multi-Specialty
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0059044Medicaid