Healthcare Provider Details

I. General information

NPI: 1770749996
Provider Name (Legal Business Name): GAIL WEISEND LISW - S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4368 DRESSLER RD NW #103
CANTON OH
44718
US

IV. Provider business mailing address

4368 DRESSLER RD NW #103
CANTON OH
44718-2771
US

V. Phone/Fax

Practice location:
  • Phone: 330-433-1300
  • Fax:
Mailing address:
  • Phone: 330-433-1300
  • Fax: 330-494-0828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI1000326
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: