Healthcare Provider Details

I. General information

NPI: 1174567291
Provider Name (Legal Business Name): JOHN BONTEMPO LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 FRONT ST
BEREA OH
44017-1716
US

IV. Provider business mailing address

429 FRONT ST
BEREA OH
44017-1716
US

V. Phone/Fax

Practice location:
  • Phone: 440-234-1900
  • Fax: 440-234-2072
Mailing address:
  • Phone: 440-234-1900
  • Fax: 440-234-2072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-7113
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: