Provider Demographics
NPI:1669092433
Name:RISTAU, TAMMY SUE (LSW)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:SUE
Last Name:RISTAU
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:SUE
Other - Last Name:RISTAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:6131 VOTAW DR
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-9446
Mailing Address - Country:US
Mailing Address - Phone:216-253-1709
Mailing Address - Fax:
Practice Address - Street 1:6131 VOTAW DR
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-9446
Practice Address - Country:US
Practice Address - Phone:216-253-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0024218104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker