Provider Demographics
NPI:1023481306
Name:STRATHERN MISENCIK, TERESE (MA,LICDC)
Entity type:Individual
Prefix:
First Name:TERESE
Middle Name:
Last Name:STRATHERN MISENCIK
Suffix:
Gender:F
Credentials:MA,LICDC
Other - Prefix:
Other - First Name:TERESE
Other - Middle Name:
Other - Last Name:MISENCIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICDC
Mailing Address - Street 1:9921 GABRIELS WAY
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6683
Mailing Address - Country:US
Mailing Address - Phone:440-223-5450
Mailing Address - Fax:440-534-1485
Practice Address - Street 1:7757 AUBURN RD
Practice Address - Street 2:SUITE 4
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-9609
Practice Address - Country:US
Practice Address - Phone:440-223-5450
Practice Address - Fax:440-534-1485
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH081201101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)