Provider Demographics
NPI:1104286905
Name:FRYSON, KRISTINA (MSW, LISW)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:FRYSON
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7519 MENTOR AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5410
Mailing Address - Country:US
Mailing Address - Phone:440-701-6170
Mailing Address - Fax:440-527-8043
Practice Address - Street 1:4565 DRESSLER RD NW STE 112
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2576
Practice Address - Country:US
Practice Address - Phone:330-765-5160
Practice Address - Fax:440-527-8043
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.23044731041C0700X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0264349Medicaid