Healthcare Provider Details

I. General information

NPI: 1386200137
Provider Name (Legal Business Name): KRISTIN MARIE CIPOLLA LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CARNEGIE AVE
CLEVELAND OH
44115-2641
US

IV. Provider business mailing address

10605 GREENHAVEN PKWY
BRECKSVILLE OH
44141-1628
US

V. Phone/Fax

Practice location:
  • Phone: 440-260-8300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1901454
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: