Provider Demographics
NPI:1275518896
Name:PANNETTE, DOUGLAS PAUL (LISW-S)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PAUL
Last Name:PANNETTE
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10020 LYNN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-1424
Mailing Address - Country:US
Mailing Address - Phone:216-406-0825
Mailing Address - Fax:
Practice Address - Street 1:8000 TOWN CENTRE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:BROADVIEW HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44147-4030
Practice Address - Country:US
Practice Address - Phone:440-627-6962
Practice Address - Fax:440-627-6963
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00087111041C0700X
MI68010591531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH515293OtherVALUE OPTIONS
OH094872000OtherMAGELLAN MIS
OH515293OtherVALUE OPTIONS