Healthcare Provider Details

I. General information

NPI: 1063154318
Provider Name (Legal Business Name): GINA TALERICO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2736 MEDINA RD STE 108
MEDINA OH
44256-9801
US

IV. Provider business mailing address

2736 MEDINA RD STE 108
MEDINA OH
44256-9801
US

V. Phone/Fax

Practice location:
  • Phone: 330-952-0403
  • Fax:
Mailing address:
  • Phone: 330-952-0403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-68858
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: