Healthcare Provider Details

I. General information

NPI: 1407358401
Provider Name (Legal Business Name): ELISABETH J. GRUBER DILLARD LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 BOETTLER RD STE 100
UNIONTOWN OH
44685-7793
US

IV. Provider business mailing address

PO BOX 932909
CLEVELAND OH
44193-2909
US

V. Phone/Fax

Practice location:
  • Phone: 330-896-0009
  • Fax: 330-896-0032
Mailing address:
  • Phone: 330-854-4281
  • Fax: 330-854-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1800849
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: