Provider Demographics
NPI:1316614829
Name:TASSIELLIMENTALHEALTHANDWELLNESS LLC
Entity type:Organization
Organization Name:TASSIELLIMENTALHEALTHANDWELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRONE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP-BC
Authorized Official - Phone:937-502-4567
Mailing Address - Street 1:3085 WOODMAN DR STE 205
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1171
Mailing Address - Country:US
Mailing Address - Phone:937-502-4567
Mailing Address - Fax:609-293-0270
Practice Address - Street 1:3085 WOODMAN DR STE 205
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45420-1171
Practice Address - Country:US
Practice Address - Phone:937-502-4567
Practice Address - Fax:609-293-0270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0458021Medicaid