Provider Demographics
NPI:1891348405
Name:BEACH GLASS PSYCHOLOGY LLC
Entity Type:Organization
Organization Name:BEACH GLASS PSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:YEZZI-SHAREEF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:440-570-5458
Mailing Address - Street 1:36144 CENTER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-2938
Mailing Address - Country:US
Mailing Address - Phone:440-570-5458
Mailing Address - Fax:
Practice Address - Street 1:37000 CENTER RIDGE ROAD
Practice Address - Street 2:SUITE 3 LOWER LEVEL
Practice Address - City:NORTH RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039-2804
Practice Address - Country:US
Practice Address - Phone:440-570-5458
Practice Address - Fax:440-628-2422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0247177Medicaid