Provider Demographics
NPI:1063526846
Name:SUPAN, DORI J (LISW)
Entity type:Individual
Prefix:MRS
First Name:DORI
Middle Name:J
Last Name:SUPAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24400 HIGHPOINT RD
Mailing Address - Street 2:STE 6
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-831-6550
Mailing Address - Fax:216-831-6133
Practice Address - Street 1:24400 HIGHPOINT RD
Practice Address - Street 2:STE 6
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-831-6550
Practice Address - Fax:216-831-6133
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0027662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSOSW24041Medicare ID - Type Unspecified