MEDICARE: STACEY R BURGE LISW-SUPV

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.0009345-SUPV	OH

General Provider Information

NPI Number	:	1124250485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY R BURGE LISW-SUPV

Provider Business Mailing Address
First Line	:	2747 LOSANTIVILLE AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45213-1265
Country	:	US
Telephone Number	:	513-633-8451
Fax Number	:	513-896-5682

Provider Business Practice Location Address
First Line	:	2747 LOSANTIVILLE AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45213-1265
Country	:	US
Telephone Number	:	513-633-8451
Fax Number	:

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

Provider Enumeration Date	:	08/19/2009
Last Update Date	:	07/24/2024

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