=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881333920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDRIA A REMY LISW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2022
-----------------------------------------------------
Last Update Date | 05/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4636 CAMELLIA LN
-----------------------------------------------------
City | NORTH OLMSTED
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44070-2458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-351-7764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4636 CAMELLIA LN
-----------------------------------------------------
City | NORTH OLMSTED
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44070-2458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-351-7764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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.2203506
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------