MEDICARE: KENNETH TAGLIARINA 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	1041C0700X	Clinical Social Worker	I.1500312	OH

General Provider Information

NPI Number	:	1124554696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH TAGLIARINA LISW

Provider Business Mailing Address
First Line	:	202 E BAGLEY RD
Second Line	:
City	:	BEREA
State	:	OH
Zip	:	44017-2058
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2749 WOODHILL RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-3660
Country	:	US
Telephone Number	:	216-707-6000
Fax Number	:

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

Provider Enumeration Date	:	05/03/2017
Last Update Date	:	05/03/2017

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