Healthcare Provider Details

I. General information

NPI: 1952762759
Provider Name (Legal Business Name): QIANA RUSSELL LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-4517
US

IV. Provider business mailing address

4636 W 149TH ST
CLEVELAND OH
44135-3422
US

V. Phone/Fax

Practice location:
  • Phone: 216-363-2122
  • Fax:
Mailing address:
  • Phone: 216-377-9102
  • Fax: 440-843-1626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSS1101115
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2203970
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: