=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356787667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERISE BOGAN LISW-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2013
-----------------------------------------------------
Last Update Date | 08/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 676 S BROADWAY ST STE 203
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44311-1059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-375-6887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1815 W MARKET ST
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44313-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-715-1105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I. 1600626
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------