Healthcare Provider Details

I. General information

NPI: 1548468440
Provider Name (Legal Business Name): MARLO JEANETTE HARVEY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 COPLEY RD
AKRON OH
44320-2709
US

IV. Provider business mailing address

4647 RENWORTH AVE NE
CANTON OH
44714-1194
US

V. Phone/Fax

Practice location:
  • Phone: 216-374-7270
  • Fax:
Mailing address:
  • Phone: 330-437-6838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberI1700023
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI1700023
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI1700023
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA-1722
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: