MEDICARE: DE-SHAWNAY BETTIEANA-TANIESHA DANIELS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	373H00000X	Day Training/Habilitation Specialist		OH

General Provider Information

NPI Number	:	1710680178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DE-SHAWNAY BETTIEANA-TANIESHA DANIELS

Provider Business Mailing Address
First Line	:	1613 2ND ST NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44704-1705
Country	:	US
Telephone Number	:	330-371-8985
Fax Number	:

Provider Business Practice Location Address
First Line	:	1613 2ND ST NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44704-1705
Country	:	US
Telephone Number	:	330-371-8985
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2023
Last Update Date	:	03/24/2023

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