=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528465598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL KUNTZ LISW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2014
-----------------------------------------------------
Last Update Date | 04/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24600 CENTER RIDGE RD STE 130
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44145-5679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-570-3790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24600 CENTER RIDGE RD STE 130
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44145-5679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-570-3790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | I.1451245
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------