Healthcare Provider Details

I. General information

NPI: 1164093175
Provider Name (Legal Business Name): ADWOA OBOSU-BAXTER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33355 HEALTH CAMPUS BLVD
AVON OH
44011-1399
US

IV. Provider business mailing address

133 COLUMBUS ST
ELYRIA OH
44035-5130
US

V. Phone/Fax

Practice location:
  • Phone: 440-937-9099
  • Fax:
Mailing address:
  • Phone: 440-989-7860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2102929
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: