Healthcare Provider Details

I. General information

NPI: 1437822889
Provider Name (Legal Business Name): MARTA H VIGERSTAD LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8224 MENTOR AVE STE 208
MENTOR OH
44060-5743
US

IV. Provider business mailing address

8224 MENTOR AVE STE 208
MENTOR OH
44060-5743
US

V. Phone/Fax

Practice location:
  • Phone: 440-392-2222
  • Fax: 440-565-2349
Mailing address:
  • Phone: 440-392-2222
  • Fax: 440-565-2349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2102955
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: