Provider Demographics
NPI:1275050148
Name:DIBIASIO, PAMELA ANN (LSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANN
Last Name:DIBIASIO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NORTHWEST AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1808
Mailing Address - Country:US
Mailing Address - Phone:330-633-4187
Mailing Address - Fax:330-633-4294
Practice Address - Street 1:30 NORTHWEST AVE
Practice Address - Street 2:BUILDING A, SUITE 120
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-4427
Practice Address - Country:US
Practice Address - Phone:330-633-4187
Practice Address - Fax:330-633-4294
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS17009751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical