=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457746588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELLE RISSER LISW, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2015
-----------------------------------------------------
Last Update Date | 04/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 E WILSON BRIDGE RD SUITE 250
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43085-2354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-582-1734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2183 OTTER LN
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43016-9067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-582-1734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHELLE RISSER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-582-1734
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0700128
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------