Basic Information
| Provider Information | |||||||||
| NPI: | 1801312640 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONDOUCH | ||||||||
| FirstName: | YAROSLAV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3413 FRIAR DR | ||||||||
| Address2: | |||||||||
| City: | PARMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441345520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408640986 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20600 CHAGRIN BLVD STE 620 | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167514762 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2017 | ||||||||
| LastUpdateDate: | 08/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | RN.378568 | OH | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.