Provider Demographics
NPI:1679958102
Name:PINES, DAVID JR (LCDCIII)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PINES
Suffix:JR
Gender:M
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5650
Mailing Address - Country:US
Mailing Address - Phone:440-887-1100
Mailing Address - Fax:440-887-1100
Practice Address - Street 1:14707 S CHESHIRE ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:OH
Practice Address - Zip Code:44021-9601
Practice Address - Country:US
Practice Address - Phone:440-887-1100
Practice Address - Fax:440-887-1103
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHAPS.001719175T00000X
OH141005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0372835Medicaid