Healthcare Provider Details

I. General information

NPI: 1508481615
Provider Name (Legal Business Name): MADELEINE FRAZIER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25700 SCIENCE PARK DR STE 200
BEACHWOOD OH
44122-7328
US

IV. Provider business mailing address

25700 SCIENCE PARK DR STE 200
BEACHWOOD OH
44122-7328
US

V. Phone/Fax

Practice location:
  • Phone: 216-831-1040
  • Fax: 216-831-2667
Mailing address:
  • Phone: 216-831-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109443
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2304318
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: