Healthcare Provider Details

I. General information

NPI: 1144528332
Provider Name (Legal Business Name): DAVID J. MENKE LISW, SAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2592 W 14TH ST
CLEVELAND OH
44113-4409
US

IV. Provider business mailing address

2592 W 14TH ST
CLEVELAND OH
44113-4409
US

V. Phone/Fax

Practice location:
  • Phone: 216-502-2209
  • Fax:
Mailing address:
  • Phone: 216-502-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0700443
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1200439
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: