Healthcare Provider Details

I. General information

NPI: 1447378443
Provider Name (Legal Business Name): BRENT ANTONY BASILE LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20613 BEACONSFIELD BLVD
ROCKY RIVER OH
44116-1307
US

IV. Provider business mailing address

20613 BEACONSFIELD BLVD
ROCKY RIVER OH
44116-1307
US

V. Phone/Fax

Practice location:
  • Phone: 216-374-8382
  • Fax:
Mailing address:
  • Phone: 216-374-8382
  • Fax: 216-374-8382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0700026
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: