Provider Demographics
NPI:1548758782
Name:YANETTA, STACEY L (LISW-S)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:YANETTA
Suffix:
Gender:F
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 1:9500 EUCLID AVE # P57
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0002
Mailing Address - Country:US
Mailing Address - Phone:216-444-5807
Mailing Address - Fax:216-636-2995
Practice Address - Street 1:AVON-RICHARD E. JACOBS HEALTH CENTER
Practice Address - Street 2:33100 CLEVELAND CLINIC BLVD
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011
Practice Address - Country:US
Practice Address - Phone:440-695-4000
Practice Address - Fax:216-636-2995
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0005535-SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker