Provider Demographics
NPI:1780199869
Name:QUEZADA-JUAREZ, TESS NOEL (LSW)
Entity Type:Individual
Prefix:
First Name:TESS
Middle Name:NOEL
Last Name:QUEZADA-JUAREZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NORTHWEST AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1808
Mailing Address - Country:US
Mailing Address - Phone:330-633-4187
Mailing Address - Fax:
Practice Address - Street 1:30 NORTHWEST AVE STE 120
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-1808
Practice Address - Country:US
Practice Address - Phone:330-633-4187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
OHS.1701519104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251S00000XAgenciesCommunity/Behavioral Health