=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407358401
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISABETH J. GRUBER DILLARD LISW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2018
-----------------------------------------------------
Last Update Date | 01/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 BOETTLER RD STE 100
-----------------------------------------------------
City | UNIONTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44685-7793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-896-0009
-----------------------------------------------------
Fax | 330-896-0032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 932909
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44193-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-854-4281
-----------------------------------------------------
Fax | 330-854-0032
-----------------------------------------------------
=====================================================
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.1800849
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------