Healthcare Provider Details

I. General information

NPI: 1558851691
Provider Name (Legal Business Name): MADDISON L MILES LISWS, LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3094 W MARKET ST STE 105
FAIRLAWN OH
44333-3617
US

IV. Provider business mailing address

434 EASTLAND RD
BEREA OH
44017-1217
US

V. Phone/Fax

Practice location:
  • Phone: 440-260-8300
  • Fax:
Mailing address:
  • Phone: 440-234-2006
  • Fax: 330-453-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2506367
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162841
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberI.2506367
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: