Provider Demographics
NPI:1619389954
Name:PURNELL, TIESHA (EDS, NCSP)
Entity Type:Individual
Prefix:MRS
First Name:TIESHA
Middle Name:
Last Name:PURNELL
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2879 CHAMBERLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-4504
Mailing Address - Country:US
Mailing Address - Phone:330-931-8531
Mailing Address - Fax:
Practice Address - Street 1:23401 EMERY RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-5142
Practice Address - Country:US
Practice Address - Phone:216-295-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20805539103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool