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General NPI Number Information
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NPI Number | 1629754122
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Entity Type | Individual
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Provider Name | KHANNAH KEZIAH WETMORE LISW
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Gender | Female
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Dates
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Enumeration Date | 06/27/2023
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Last Update Date | 06/27/2023
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Provider Practice Location Address
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Address Line | 23625 COMMERCE PARK STE 100
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City | BEACHWOOD
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State | OH
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Zip | 44122-5847
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Country | US
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Telephone | 216-468-5000
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Fax | 216-831-4410
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Provider Business Mailing Address
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Address Line | 341 E 235TH ST
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City | EUCLID
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State | OH
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Zip | 44123-1509
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Country | US
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Telephone | 620-253-4179
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | I.2204081
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License Number State | OH
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