Healthcare Provider Details

I. General information

NPI: 1598300352
Provider Name (Legal Business Name): MERISSA ANN DURDA LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25700 SCIENCE PARK DR STE 210
BEACHWOOD OH
44122-7328
US

IV. Provider business mailing address

PO BOX 844020
DALLAS TX
75284-4020
US

V. Phone/Fax

Practice location:
  • Phone: 216-450-1613
  • Fax: 216-450-1614
Mailing address:
  • Phone: 216-450-1613
  • Fax: 216-450-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI.1302478-SUPV
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1302478-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: