MEDICARE: PAMELA PEEK LISW-S

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	1041C0700X	Clinical Social Worker	I0007576	OH

General Provider Information

NPI Number	:	1043563307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA PEEK LISW-S

Provider Business Mailing Address
First Line	:	7267 LYNBROOK DR
Second Line	:
City	:	OAKWOOD VILLAGE
State	:	OH
Zip	:	44146-5909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5241 WILSON MILLS RD
Second Line	:	SUITE 24
City	:	CLEVELAND
State	:	OH
Zip	:	44143-2150
Country	:	US
Telephone Number	:	216-926-8879
Fax Number	:

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

Provider Enumeration Date	:	10/23/2012
Last Update Date	:	10/23/2012

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