MEDICARE: MRS. BRITNEY SHALE BRUCE LISW-S

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	104100000X	Social Worker	S.1701041	OH
2	104100000X	Social Worker	I.2203667	OH

General Provider Information

NPI Number	:	1104343136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRITNEY SHALE BRUCE LISW-S

Provider Business Mailing Address
First Line	:	4179 EBENEZER RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45248-1505
Country	:	US
Telephone Number	:	513-574-1205
Fax Number	:	513-574-1206

Provider Business Practice Location Address
First Line	:	4179 EBENEZER RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45248-1505
Country	:	US
Telephone Number	:	513-574-1205
Fax Number	:	513-574-1206

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

Provider Enumeration Date	:	08/30/2017
Last Update Date	:	08/09/2023

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