Healthcare Provider Details

I. General information

NPI: 1306240072
Provider Name (Legal Business Name): TINA MARIE TOMCKO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2014
Last Update Date: 10/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 MIDWAY BLVD STE 200
ELYRIA OH
44035-2496
US

IV. Provider business mailing address

347 MIDWAY BLVD STE 200
ELYRIA OH
44035-2496
US

V. Phone/Fax

Practice location:
  • Phone: 440-324-5701
  • Fax:
Mailing address:
  • Phone: 440-324-5701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.0500936
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: