Healthcare Provider Details

I. General information

NPI: 1205492709
Provider Name (Legal Business Name): SHANICE CAMPBELL LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

IV. Provider business mailing address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

V. Phone/Fax

Practice location:
  • Phone: 216-320-6811
  • Fax:
Mailing address:
  • Phone: 216-320-6118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2507527
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: