MEDICARE: TOBY BOURISSEAU CNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN.CNS.08218	OH
2	364SP0807X	Child & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist	08218	OH

General Provider Information

NPI Number	:	1790807006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOBY BOURISSEAU CNS

Provider Business Mailing Address
First Line	:	10524 EUCLID AVE STE 1155A
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-2205
Country	:	US
Telephone Number	:	216-844-3881
Fax Number	:

Provider Business Practice Location Address
First Line	:	10524 EUCLID AVE STE 1155A
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-2205
Country	:	US
Telephone Number	:	216-844-3881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	06/29/2026

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