=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932699683
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA M MARTONCHIK LISW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2018
-----------------------------------------------------
Last Update Date | 09/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 398 W BAGLEY RD STE 13
-----------------------------------------------------
City | BEREA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44017-1312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-970-3790
-----------------------------------------------------
Fax | 440-527-8043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7519 MENTOR AVE STE 114
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-5410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-701-6170
-----------------------------------------------------
Fax | 440-527-8043
-----------------------------------------------------
=====================================================
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.2405818
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------