MEDICARE: KATHLEEN MARIE SHANNON 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	104100000X	Social Worker	I.0003968-SUPV	OH
2	104100000X	Social Worker	I0003968	OH

General Provider Information

NPI Number	:	1225137219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MARIE SHANNON LISW

Provider Business Mailing Address
First Line	:	615 ELSINORE PL STE 200
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45202-1459
Country	:	US
Telephone Number	:	513-834-7063
Fax Number	:	513-873-1567

Provider Business Practice Location Address
First Line	:	930 TRAILWOOD DR
Second Line	:
City	:	BOARDMAN
State	:	OH
Zip	:	44512-5007
Country	:	US
Telephone Number	:	513-834-7063
Fax Number	:	513-873-1567

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	09/03/2020

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