Provider Demographics
NPI:1417559444
Name:TISH, LEE
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:TISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 E HENRY ST
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-4225
Mailing Address - Country:US
Mailing Address - Phone:330-317-6822
Mailing Address - Fax:
Practice Address - Street 1:705 BEALL AVE APT 4
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2978
Practice Address - Country:US
Practice Address - Phone:330-317-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0400747376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker