Healthcare Provider Details

I. General information

NPI: 1558387514
Provider Name (Legal Business Name): KATHLEEN BALCERZAK LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WOODBRIDGE TRL
SAGAMORE HILLS OH
44067-2591
US

IV. Provider business mailing address

PO BOX 660
MENTOR OH
44061-0660
US

V. Phone/Fax

Practice location:
  • Phone: 216-662-7222
  • Fax:
Mailing address:
  • Phone: 440-854-0217
  • Fax: 440-516-3783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0000774
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: