Healthcare Provider Details

I. General information

NPI: 1053532663
Provider Name (Legal Business Name): TARYN JESSICA PONSKY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19910 MALVERN RD
SHAKER HEIGHTS OH
44122
US

IV. Provider business mailing address

2370 WOODMERE DRIVE
CLEVELAND HEIGHTS OH
44106-4410
US

V. Phone/Fax

Practice location:
  • Phone: 216-991-4472
  • Fax:
Mailing address:
  • Phone: 216-321-1909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.0500986
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: