Healthcare Provider Details

I. General information

NPI: 1316614829
Provider Name (Legal Business Name): TASSIELLIMENTALHEALTHANDWELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3085 WOODMAN DR STE 205
KETTERING OH
45420-1171
US

IV. Provider business mailing address

3085 WOODMAN DR STE 205
KETTERING OH
45420-1171
US

V. Phone/Fax

Practice location:
  • Phone: 937-502-4567
  • Fax: 609-293-0270
Mailing address:
  • Phone: 937-502-4567
  • Fax: 609-293-0270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: LIDIA BERRONE
Title or Position: OWNER
Credential: APRN, PMHNP-BC
Phone: 937-502-4567