Provider Demographics
NPI:1487272225
Name:AUTHENTIC PRIDE THERAPY LLC
Entity type:Organization
Organization Name:AUTHENTIC PRIDE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EMERSON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:216-400-5709
Mailing Address - Street 1:5782 ANDREWS RD APT I103
Mailing Address - Street 2:
Mailing Address - City:MENTOR ON THE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44060-2659
Mailing Address - Country:US
Mailing Address - Phone:216-400-5709
Mailing Address - Fax:
Practice Address - Street 1:25201 CHAGRIN BLVD STE 390
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5637
Practice Address - Country:US
Practice Address - Phone:216-400-5709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty