Healthcare Provider Details

I. General information

NPI: 1891033510
Provider Name (Legal Business Name): DAVID STROM LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 03/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142 KADENA AB OKINAWA JAPAN
APO AP
96367-9998
US

IV. Provider business mailing address

PSC 80 BOX 13593
APO AP
96367-9998
US

V. Phone/Fax

Practice location:
  • Phone: 315-634-0433
  • Fax:
Mailing address:
  • Phone: 315-634-0433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2593
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: