Provider Demographics
NPI:1447884044
Name:OTIS, TYHESHA (CDCA)
Entity type:Individual
Prefix:
First Name:TYHESHA
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 WOODLAND AVE STE 703
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-2775
Mailing Address - Country:US
Mailing Address - Phone:216-315-8120
Mailing Address - Fax:
Practice Address - Street 1:6001 WOODLAND AVE STE 703
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-2775
Practice Address - Country:US
Practice Address - Phone:216-315-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA-166247101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty