Provider Demographics
NPI:1245776749
Name:DERRY, TARELL (LSW)
Entity Type:Individual
Prefix:
First Name:TARELL
Middle Name:
Last Name:DERRY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:DERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3737 LANDER RD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5712
Mailing Address - Country:US
Mailing Address - Phone:216-831-2255
Mailing Address - Fax:
Practice Address - Street 1:3737 LANDER RD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5712
Practice Address - Country:US
Practice Address - Phone:216-831-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0007181104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker