MEDICARE: MS. AUTHELIA UPDEGRAFF 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	I9530	OH

General Provider Information

NPI Number	:	1851345987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AUTHELIA UPDEGRAFF LISW

Provider Business Mailing Address
First Line	:	24800 HIGHPOINT RD
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-6041
Country	:	US
Telephone Number	:	216-831-6611
Fax Number	:	216-831-2726

Provider Business Practice Location Address
First Line	:	2770 SOM CENTER RD
Second Line	:	#2
City	:	WILLOUGHBY
State	:	OH
Zip	:	44094-9111
Country	:	US
Telephone Number	:	440-516-1350
Fax Number	:	440-944-7330

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

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	07/08/2007

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