Provider Demographics
NPI:1689770505
Name:DISERIO, THERESA RUTH (PHD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:RUTH
Last Name:DISERIO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:DISERIO
Other - Last Name:RAMSAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:3831 ATTUCKS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-6082
Mailing Address - Country:US
Mailing Address - Phone:614-791-0799
Mailing Address - Fax:614-791-0798
Practice Address - Street 1:3831 ATTUCKS DR
Practice Address - Street 2:STE B
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-6082
Practice Address - Country:US
Practice Address - Phone:614-791-0799
Practice Address - Fax:614-791-0798
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4337103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDICP 13681Medicare ID - Type UnspecifiedPSYCHOLOGY