Provider Demographics
NPI:1083245468
Name:TARESCAVAGE, ANTHONY MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:TARESCAVAGE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7828 W LIST LN
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44130-7129
Mailing Address - Country:US
Mailing Address - Phone:440-547-8163
Mailing Address - Fax:
Practice Address - Street 1:16600 W SPRAGUE RD STE 260
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-6319
Practice Address - Country:US
Practice Address - Phone:216-714-0092
Practice Address - Fax:216-714-0092
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7458103T00000X, 103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic