MEDICARE: DIANE ELIZABETH KRAGT 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-0008130	OH

General Provider Information

NPI Number	:	1659865871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE ELIZABETH KRAGT LISW

Provider Business Mailing Address
First Line	:	7200 FRANKLIN BLVD APT 100
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-2983
Country	:	US
Telephone Number	:	216-961-1568
Fax Number	:

Provider Business Practice Location Address
First Line	:	7200 FRANKLIN BLVD APT 100
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-2983
Country	:	US
Telephone Number	:	216-961-1568
Fax Number	:

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

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	06/20/2018

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