Healthcare Provider Details

I. General information

NPI: 1508317983
Provider Name (Legal Business Name): KATHLEEN MARUCCI LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 BROADWAY AVE
YOUNGSTOWN OH
44504
US

IV. Provider business mailing address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-4384
  • Fax:
Mailing address:
  • Phone: 330-782-5664
  • Fax: 330-782-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.901418
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: