Healthcare Provider Details

I. General information

NPI: 1124120209
Provider Name (Legal Business Name): GAYLE M MALTARICH LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 BAKER BLVD
FAIRLAWN OH
44333-3601
US

IV. Provider business mailing address

63 BAKER BLVD
FAIRLAWN OH
44333-3601
US

V. Phone/Fax

Practice location:
  • Phone: 330-864-6331
  • Fax:
Mailing address:
  • Phone: 330-864-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI10154
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: