MEDICARE: KISHA CHOICE LCSW, CAP

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	SW13910	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174189872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KISHA CHOICE LCSW, CAP

Provider Business Mailing Address
First Line	:	13377 N 56TH ST
Second Line	:
City	:	TEMPLE TERR
State	:	FL
Zip	:	33617-1161
Country	:	US
Telephone Number	:	181-270-5225
Fax Number	:	813-200-3278

Provider Business Practice Location Address
First Line	:	13377 N 56TH ST
Second Line	:
City	:	TEMPLE TERR
State	:	FL
Zip	:	33617-1161
Country	:	US
Telephone Number	:	813-270-5225
Fax Number	:	813-200-3278

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

Provider Enumeration Date	:	05/17/2019
Last Update Date	:	09/18/2020

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