Healthcare Provider Details

I. General information

NPI: 1962615518
Provider Name (Legal Business Name): ROGER J MIZE LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 CHARDON ST
PAINESVILLE OH
44077-3019
US

IV. Provider business mailing address

462 CHARDON ST
PAINESVILLE OH
44077-3019
US

V. Phone/Fax

Practice location:
  • Phone: 440-853-1501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0004936-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: