Provider Demographics
NPI:1194293357
Name:VESSEL, LEENORA SHERNITA (LSW)
Entity type:Individual
Prefix:
First Name:LEENORA
Middle Name:SHERNITA
Last Name:VESSEL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:LEENORA
Other - Middle Name:SHERNITA
Other - Last Name:VESSEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5593 GREEN BROTHERS BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8284
Mailing Address - Country:US
Mailing Address - Phone:614-591-1414
Mailing Address - Fax:
Practice Address - Street 1:5593 GREEN BROTHERS BLVD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-8284
Practice Address - Country:US
Practice Address - Phone:614-591-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1000165104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid