Healthcare Provider Details

I. General information

NPI: 1154957231
Provider Name (Legal Business Name): TAYLOR KAYLENE BUSS LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3693 TRAVER RD
SHAKER HEIGHTS OH
44122-5165
US

IV. Provider business mailing address

3693 TRAVER RD
SHAKER HEIGHTS OH
44122-5165
US

V. Phone/Fax

Practice location:
  • Phone: 216-224-0756
  • Fax:
Mailing address:
  • Phone: 216-224-0756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.1801322
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1801322
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: