MEDICARE: MS. KAY ENTE ARIEL 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	I-3066	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000222058	OTHER	OH	BC/BS

General Provider Information

NPI Number	:	1063501963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KAY ENTE ARIEL LISW

Provider Business Mailing Address
First Line	:	2460 FAIRMOUNT BLVD
Second Line	:	SUITE 320
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44106-3171
Country	:	US
Telephone Number	:	440-779-6708
Fax Number	:	216-231-7235

Provider Business Practice Location Address
First Line	:	2460 FAIRMOUNT BLVD
Second Line	:	SUITE 320
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44106-3171
Country	:	US
Telephone Number	:	440-779-6708
Fax Number	:	216-231-7235

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	08/18/2012

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