Healthcare Provider Details

I. General information

NPI: 1881942985
Provider Name (Legal Business Name): REGINA D COON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2173 N RIDGE RD E SUITE E
LORAIN OH
44055-3400
US

IV. Provider business mailing address

202 E BAGLEY RD
BEREA OH
44017-2058
US

V. Phone/Fax

Practice location:
  • Phone: 440-260-6108
  • Fax: 440-282-3400
Mailing address:
  • Phone: 440-260-8327
  • Fax: 440-260-8305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0030079
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1600623
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: