Healthcare Provider Details

I. General information

NPI: 1184079113
Provider Name (Legal Business Name): JUDITH GARDNER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 N CANTON RD
AKRON OH
44305
US

IV. Provider business mailing address

87 N CANTON RD
AKRON OH
44305-3838
US

V. Phone/Fax

Practice location:
  • Phone: 330-733-7993
  • Fax: 330-733-2242
Mailing address:
  • Phone: 330-733-7993
  • Fax: 330-733-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0005291
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: