Basic Information
| Provider Information | |||||||||
| NPI: | 1063430908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAXER-TISDALE | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 E 22ND ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441153202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164599827 | ||||||||
| FaxNumber: | 2166965638 | ||||||||
| Practice Location | |||||||||
| Address1: | 5255 N ABBE RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SHEFFIELD VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440351451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409349930 | ||||||||
| FaxNumber: | 4409349645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 04/15/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.0003132 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 000000124718 | 01 | OH | ANTHEM BLUE CROSS PIN | OTHER |