Healthcare Provider Details

I. General information

NPI: 1790027852
Provider Name (Legal Business Name): DIANA TYSON WALLACE ATR, PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 LANDER RD
CLEVELAND OH
44124-5712
US

IV. Provider business mailing address

3737 LANDER RD
CLEVELAND OH
44124-5712
US

V. Phone/Fax

Practice location:
  • Phone: 216-831-2255
  • Fax:
Mailing address:
  • Phone: 216-831-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC. 1000308
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1700151
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: