Healthcare Provider Details

I. General information

NPI: 1841731510
Provider Name (Legal Business Name): LEE SIDE WELLNESS ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date: 02/24/2022
Reactivation Date: 04/05/2022

III. Provider practice location address

3615 SOCIALVILLE FOSTER RD SUTIES A B C D
MASON OH
45040-6971
US

IV. Provider business mailing address

3615 SOCILAVILLE FOSTER RD SUITES A B C D
MASON OH
45040-6971
US

V. Phone/Fax

Practice location:
  • Phone: 513-204-1910
  • Fax: 513-204-0049
Mailing address:
  • Phone: 513-204-1910
  • Fax: 513-204-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: RONALD TYSON
Title or Position: OWNER/CEO
Credential:
Phone: 513-317-0720