Provider Demographics
NPI:1790807006
Name:BOURISSEAU, TOBY (CNS)
Entity Type:Individual
Prefix:
First Name:TOBY
Middle Name:
Last Name:BOURISSEAU
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10524 EUCLID AVE STE 1155A
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2205
Mailing Address - Country:US
Mailing Address - Phone:216-844-3881
Mailing Address - Fax:
Practice Address - Street 1:10524 EUCLID AVE STE 1155A
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-2205
Practice Address - Country:US
Practice Address - Phone:216-844-3881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08218364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent