Provider Demographics
NPI:1386153468
Name:BEACH, MICHAEL (LCDC III)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BEACH
Suffix:
Gender:M
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15561 HUMPHREY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3516
Mailing Address - Country:US
Mailing Address - Phone:216-396-7094
Mailing Address - Fax:
Practice Address - Street 1:1320 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-2333
Practice Address - Country:US
Practice Address - Phone:216-781-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0.161442101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0.161442OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD