Basic Information
| Provider Information | |||||||||
| NPI: | 1720706351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEFELICE | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | THERESA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5905 BRECKSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441311517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165244673 | ||||||||
| FaxNumber: | 2165243743 | ||||||||
| Practice Location | |||||||||
| Address1: | 5905 BRECKSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441311517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165244673 | ||||||||
| FaxNumber: | 2165243743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2022 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | S00007354 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.