Basic Information
| Provider Information | |||||||||
| NPI: | 1740730134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRACIA | ||||||||
| FirstName: | TIFFANEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4609 ANDOVER AVE | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440553524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407141251 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22001 FAIRMONT | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169322800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2016 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
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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.1600934 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.