Healthcare Provider Details

I. General information

NPI: 1750873253
Provider Name (Legal Business Name): TANYA DISSELL LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

IV. Provider business mailing address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

V. Phone/Fax

Practice location:
  • Phone: 216-932-2800
  • Fax:
Mailing address:
  • Phone: 440-578-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2410357
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: