Healthcare Provider Details

I. General information

NPI: 1093359804
Provider Name (Legal Business Name): CASSANDRA WYLIE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45875 BELL SCHOOL RD STE B
EAST LIVERPOOL OH
43920-8728
US

IV. Provider business mailing address

10792 MAIN ST
NEW MIDDLETOWN OH
44442-7729
US

V. Phone/Fax

Practice location:
  • Phone: 330-397-6007
  • Fax: 234-254-5655
Mailing address:
  • Phone: 330-774-6288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2103168-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS1600867
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: