Healthcare Provider Details

I. General information

NPI: 1053772749
Provider Name (Legal Business Name): EMILY VIZYAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 WINDHAM CT SUITE 4
BOARDMAN OH
44512-5083
US

IV. Provider business mailing address

950 WINDHAM COURT SUITE 4
BOARDMAN OH
44512-5083
US

V. Phone/Fax

Practice location:
  • Phone: 330-629-2955
  • Fax: 330-629-2956
Mailing address:
  • Phone: 330-629-2955
  • Fax: 330-629-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number156787
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: