MEDICARE: LISA RENEE LEACE LISW-S, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I.1000162	OH
2	1041C0700X	Clinical Social Worker	34007063A	IN

General Provider Information

NPI Number	:	1023540317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA RENEE LEACE LISW-S, LCSW

Provider Business Mailing Address
First Line	:	11651 NORBOURNE DR
Second Line	:	APARTMENT 1708
City	:	CINCINNATI
State	:	OH
Zip	:	45240-2100
Country	:	US
Telephone Number	:	513-378-5665
Fax Number	:

Provider Business Practice Location Address
First Line	:	11651 NORBOURNE DR
Second Line	:	APARTMENT 1708
City	:	CINCINNATI
State	:	OH
Zip	:	45240-2100
Country	:	US
Telephone Number	:	513-378-5665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	03/28/2017

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