MEDICARE: SHELLEY ANNE SOVIAK LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	S0031843	OH
2	1041C0700X	Clinical Social Worker	I0800102	OH

General Provider Information

NPI Number	:	1023103447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY ANNE SOVIAK LISW

Provider Business Mailing Address
First Line	:	453 ALLENBY DRIVE
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040
Country	:	US
Telephone Number	:	937-642-0048
Fax Number	:	937-642-1316

Provider Business Practice Location Address
First Line	:	453 ALLENBY DR
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-8722
Country	:	US
Telephone Number	:	937-642-0048
Fax Number	:	937-642-1316

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	04/15/2008

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