Provider Demographics
NPI:1154966745
Name:DAVIS-FLETCHER, EDITH
Entity type:Individual
Prefix:MS
First Name:EDITH
Middle Name:
Last Name:DAVIS-FLETCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 GREENVALE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1116
Mailing Address - Country:US
Mailing Address - Phone:216-254-5793
Mailing Address - Fax:
Practice Address - Street 1:2400 GREENVALE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44121-1116
Practice Address - Country:US
Practice Address - Phone:216-254-5793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA170996101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH170996Medicaid