Provider Demographics
NPI:1306260252
Name:IANETTA, ALISSA (PSYS)
Entity type:Individual
Prefix:MRS
First Name:ALISSA
Middle Name:
Last Name:IANETTA
Suffix:
Gender:F
Credentials:PSYS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7221 HARMONY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-3198
Mailing Address - Country:US
Mailing Address - Phone:440-224-2515
Mailing Address - Fax:
Practice Address - Street 1:7221 HARMONY GLEN DR
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030-3198
Practice Address - Country:US
Practice Address - Phone:440-224-2515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1416355103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool