Healthcare Provider Details

I. General information

NPI: 1902512809
Provider Name (Legal Business Name): MELISSA PANTEL-KU LISW-S LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19910 MALVERN RD STE 201
SHAKER HEIGHTS OH
44122-2823
US

IV. Provider business mailing address

17666 STOCKTON LN
CHAGRIN FALLS OH
44023-5741
US

V. Phone/Fax

Practice location:
  • Phone: 440-227-1955
  • Fax:
Mailing address:
  • Phone: 440-227-1955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA PANTEL-KU
Title or Position: OWNER/MEMBER
Credential: LISW-S
Phone: 440-227-1955