=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689058273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARISSA MALCOLM LISW-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2015
-----------------------------------------------------
Last Update Date | 12/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 E 194TH ST
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44119-1030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-789-9536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 E 194TH ST
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44119-1030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-753-6287
-----------------------------------------------------
Fax | 440-383-8874
-----------------------------------------------------
=====================================================
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 | S.0026177
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.1700018-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------