Healthcare Provider Details

I. General information

NPI: 1316792674
Provider Name (Legal Business Name): CAMRYN AMELIA SMITH LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17951 JEFFERSON PARK RD STE 100
MIDDLEBURG HEIGHTS OH
44130-8439
US

IV. Provider business mailing address

29228 REGENCY CIR
WESTLAKE OH
44145-6701
US

V. Phone/Fax

Practice location:
  • Phone: 440-879-8517
  • Fax: 440-445-0879
Mailing address:
  • Phone: 216-213-2503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2608706
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: